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Appiah D, Chaudhury H, Chaudhury T, Iweh M, Shabaneh O, De La Cruz N. The Risk of Cardiovascular Disease Risk Among Adults with Vision Impairment from Low-, Middle- and High-Income Countries. Ophthalmic Epidemiol 2024:1-8. [PMID: 38833627 DOI: 10.1080/09286586.2024.2354695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/02/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE The limited evidence for cardiovascular disease (CVD) among adults with vision impairment (VI) has often been from developed countries using self-reported VI. This study evaluated the association of objectively-determined VI with the risk of CVD among adults from low-, middle-, and high-income countries. METHODS Data were from 32,268 adults aged 30-74 years without CVD or blindness from China, Ghana, India, Mexico, Russian Federation, South Africa, and the United States during 2007-2010. VI and severe VI was defined as presenting visual acuity worse than 6/18, and 6/60, respectively. The Framingham risk algorithm was used to estimate the risk for incident CVD. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals. RESULTS The mean age of participants was 46.4 years, with half of them being women (49.3%). The age-adjusted prevalence of VI ranged from 1.1% (United States) to 14.2% (South Africa) while severe VI ranged from 0.4% (United States) to 4.5% (Ghana). In models adjusting for country, sociodemographic factors, waist girth, healthcare use, activities of daily living and other health-related factors, VI was associated with CVD risk ≥ 10% (OR = 1.69, 95% CI: 1.22-2.36). This observed association was largely consistent across countries (p = 0.119). The observed CVD risk was similar among adults with moderate or severe VI (OR = 0.95, 95% CI: 0.50-1.83). CVD risk was higher among adults with VI who were <65 years old (OR = 1.89, 95% CI: 1.36-2.63) or were employed (OR = 2.24, 95% CI: 1.58-3.16). CONLUSIONS This cross-national study shows that individuals with VI are at high risk for future CVD.
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Affiliation(s)
- Duke Appiah
- Department of Public Health, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Hannah Chaudhury
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Tristin Chaudhury
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Marvelyn Iweh
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Obadeh Shabaneh
- School of Medicine, St. George's University, St. George's, Grenada
| | - Noah De La Cruz
- College of Osteopathic Medicine, Sam Houston State University, Conroe, Texas, USA
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Srivastava S, Kumar M, Muhammad T, Debnath P. Prevalence and predictors of vision impairment among older adults in India: evidence from LASI, 2017-18. BMC Ophthalmol 2023; 23:251. [PMID: 37277715 DOI: 10.1186/s12886-023-03009-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/31/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Older adults experience a natural decline in health, physical and cognitive functionality, and vision impairment (VI) is one among them and has become an increasing health concern worldwide. The present study assessed the association of chronic morbidities such as diabetes, hypertension, stroke, heart diseases and various socioeconomic factors with VI among older Indian adults. METHODS Data for this study were derived from the nationally-representative Longitudinal Ageing Study in India (LASI), wave-1 (2017-18). VI was assessed using the cut-off of visual acuity worse than 20/80, and additional analysis was carried out using the definition of VI with a cut-off of visual acuity worse than 20/63. Descriptive statistics along with cross-tabulation were presented in the study. Proportion test was used to evaluate the significance level for sex differentials in VI among older adults. Additionally, multivariable logistic regression analysis was conducted to explore the factors associated with VI among older adults. RESULTS About 33.8% of males and 40% of females suffered from VI in India (visual acuity worse than 20/80). Meghalaya (59.5%) had the highest prevalence for VI among older males followed by Arunachal Pradesh (58.4%) and Tripura (45.2%). Additionally, Arunachal Pradesh (77.4%) had the highest prevalence for VI among females followed by Meghalaya (68.8%) and Delhi (56.1%). Among the health factors, stroke [AOR: 1.20; CI: 1.03-1.53] and hypertension [AOR: 1.12; CI: 1.01-1.22] were the significant risk factors for VI among older adults. Additionally, being oldest old [AOR: 1.58; CI: 1.32-1.89] and divorced/separated/deserted/others [AOR: 1.42; CI: 1.08-1.87] were significantly associated with VI. Moreover, older adults with higher educational status [AOR: 0.42; CI: 0.34, 0.52], currently working [AOR: 0.77; CI: 0.67, 0.88], from urban areas [AOR: 0.86; CI: 0.76-0.98] and from western region [AOR: 0.55; CI: 0.48-0.64] had lower odds of VI in this study. CONCLUSION This study identified higher rates of VI among those who are diagnosed with hypertension or stroke, currently unmarried, socioeconomically poorer, less educated and urban resident older people that can inform strategies to engage high risk groups. The findings also suggest that specific interventions that promote active aging are required for those who are socioeconomically disadvantaged as well as visually impaired.
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Affiliation(s)
- Shobhit Srivastava
- International Institute for Population Sciences, Mumbai, Maharashtra, 400088, India
| | - Manish Kumar
- International Institute for Population Sciences, Mumbai, Maharashtra, 400088, India
| | - T Muhammad
- International Institute for Population Sciences, Mumbai, Maharashtra, 400088, India.
| | - Paramita Debnath
- International Institute for Population Sciences, Mumbai, Maharashtra, 400088, India
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Mendez I, Kim M, Lundeen EA, Loustalot F, Fang J, Saaddine J. Cardiovascular Disease Risk Factors in US Adults With Vision Impairment. Prev Chronic Dis 2022; 19:E43. [PMID: 35862513 PMCID: PMC9336192 DOI: 10.5888/pcd19.220027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Adults with vision impairment (VI) have a higher prevalence of cardiovascular disease (CVD) compared with those without VI. We estimated the prevalence of CVD and CVD risk factors by VI status in US adults. METHODS We used nationally representative data from the 2018 National Health Interview Survey (N = 22,890 adults aged ≥18 years). We estimated the prevalence of self-reported diagnosis of CVD (coronary heart disease [including angina and myocardial infarction], stroke, or other heart disease) by VI status. We used separate logistic regression models to generate adjusted prevalence ratios (aPRs), controlling for sociodemographic covariates, for those with VI (reference group, no VI) for CVD and CVD risk factors: current smoking, physical inactivity, excessive alcohol intake, obesity, hypertension, high cholesterol, and diabetes. RESULTS Overall, 12.9% (95% CI, 12.3-13.5) of the sample had VI. The prevalence of CVD was 26.6% (95% CI, 24.7-28.6) in people with VI versus 12.2% (95% CI, 11.7-12.8) in those without VI (aPR = 1.65 [95% CI, 1.51-1.80]). Compared with adults without VI, those with VI had a higher prevalence of all risk factors examined: current smoking (aPR = 1.40 [95% CI, 1.27-1.53]), physical inactivity (aPR = 1.14 [95% CI, 1.06-1.22]), excessive alcohol intake (aPR = 1.29 [95% CI, 1.08-1.53]), obesity (aPR = 1.28 [95% CI, 1.21-1.36]), hypertension (aPR = 1.29 [95% CI, 1.22-1.36]), high cholesterol (aPR = 1.21 [95% CI, 1.14-1.29]), and diabetes (aPR = 1.54 [95% CI, 1.38-1.72]). CONCLUSION Adults with VI had a higher prevalence of CVD and CVD risk factors compared with those without VI. Effective clinical and lifestyle interventions, adapted to accommodate VI-related challenges, may help reduce CVD risk in adults with VI.
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Affiliation(s)
- Isabel Mendez
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.,Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mail Stop S107-3, Atlanta, GA 30341.
| | - Minchul Kim
- University of Illinois College of Medicine, Peoria, Illinois
| | - Elizabeth A Lundeen
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Fleetwood Loustalot
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jing Fang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jinan Saaddine
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Wettstein M, Werner-Wahl H, Spuling SM. Nine-year changes in self-reported problems with vision and hearing among older adults: do subjective age views matter? Aging Ment Health 2021; 25:2200-2212. [PMID: 32985229 DOI: 10.1080/13607863.2020.1822290] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES So far, little is known about linkages between subjective age views and long-term changes in vision and hearing. METHOD We examined the predictive role of two key measures of subjective age views (attitude toward own aging [ATOA]; aging-related cognitions comprising continuous growth, social loss, and physical decline) for changes in self-reported problems with vision and hearing over a period of up to 9 years. A subsample of the German Ageing Survey was used, consisting of 2,499 older adults. RESULTS Controlling for socio-demographic characteristics, self-rated health, and depressive symptoms, we found that with increasing age, more favorable ATOA scores, as well as higher scores on continuous growth and lower scores on physical decline, were associated with fewer self-reported vision problems at baseline. With advancing age, more favorable ATOA scores were also related with fewer hearing problems at baseline. However, among individuals with an older baseline age, more favorable ATOA scores were associated with a steeper increase in vision problems. Higher scores on continuous growth were related with less increase in hearing problems, independent of age. CONCLUSION Our findings suggest that subjective age views predict individuals' self-reported vision and hearing problems.
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Affiliation(s)
| | - Hans- Werner-Wahl
- Department of Psychological Ageing Research, Institute of Psychology, Heidelberg University, Heidelberg, Germany
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Abstract
Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient's aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient's function and quality of life at a time in life when these often become foremost therapeutic priorities.
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Affiliation(s)
| | - Daniel E Forman
- University of Pittsburgh, University of Pittsburgh Medical Center and VA Pittsburgh Geriatric, Research, Education and Clinical Center (GRECC), Pittsburgh, PA, USA
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Haanes GG, Roin Á, Petersen MS. Preventive Home Visit (PHV) Screening of Hearing and Vision Among Older Adults in Tórshavn, Faroe Islands: A Feasibility Study in a Small-Scale Community. J Multidiscip Healthc 2021; 14:1691-1699. [PMID: 34234456 PMCID: PMC8257060 DOI: 10.2147/jmdh.s298374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/21/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Hearing and vision loss are common in later life but often overlooked and undertreated. The study aims to examine hearing and vision as part of preventive home visits (PHV) among 76-year-old home-dwelling citizens in Tórshavn, the capital of Faroe Islands. Patients and Methods In this cross-sectional study, three specially trained nurses conducted the examinations and tests, for this purpose, in the community health-centre. Results A total of 74 individuals participated (56% participation rate) of whom 77% had some degree of hearing impairment, 89% had visual impairment and 22% had dual sensory loss. A significant correlation between self-reported hearing ability and clinical findings was found, whereas self-reported vision did not correlate significantly with test-results. Conclusion Results indicate that implementing clinical assessments of hearing and vision as part of preventive home visits would benefit people receiving visits, and society by helping maintain the conditions that allow them to stay in their own homes for as long as possible.
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Affiliation(s)
- Gro Gade Haanes
- Faculty of Health and Social Science, Institute for Nursing and Health Science, University of Southeast-Norway (USN), Borre, NO-3199, Norway
| | - Ása Roin
- Centre of Health Sciences, Faculty of Health Sciences, University of the Faroe Islands, Tórshavn, FO-100, Faroe Islands
| | - Maria Skaalum Petersen
- Centre of Health Sciences, Faculty of Health Sciences, University of the Faroe Islands, Tórshavn, FO-100, Faroe Islands.,Department of Occupational Medicine and Public Health, The Faroese Hospital System, Tórshavn, FO-100, Faroe Islands
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Wettstein M, Wahl HW, Heyl V. Perceived Stress Predicts Subsequent Self-Reported Problems With Vision and Hearing: Longitudinal Findings From the German Ageing Survey. Res Aging 2021; 44:286-300. [PMID: 34169758 PMCID: PMC8948369 DOI: 10.1177/01640275211027304] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although stress is a risk factor for various diseases in later life, its role for sensory abilities in the second half of life has rarely been empirically addressed. We examined if perceived stress at baseline predicts self-reported difficulties with vision and hearing 3 years later. We also explored whether chronological age is a moderator of associations between stress and sensory difficulties. Our sample was derived from the German Ageing Survey and consisted of n = 5,085 individuals aged 40-95 years (M = 64.01 years, SD = 10.84 years). Controlling for baseline self-reported sensory functioning, socio-demographic indicators, self-rated health and chronic diseases, greater perceived stress at baseline predicted greater self-reported difficulties with vision and hearing 3 years later. The effect of stress did not vary by age. Our findings suggest that, from middle adulthood to advanced old age, stress is a risk factor for increases in self-perceived problems with vision and hearing.
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Affiliation(s)
- Markus Wettstein
- German Centre of Gerontology, Berlin, Germany.,Heidelberg University, Germany
| | | | - Vera Heyl
- University of Education, Heidelberg, Germany
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Liljas AEM, Jones A, Cadar D, Steptoe A, Lassale C. Association of Multisensory Impairment With Quality of Life and Depression in English Older Adults. JAMA Otolaryngol Head Neck Surg 2021; 146:278-285. [PMID: 32027340 DOI: 10.1001/jamaoto.2019.4470] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Sensory acuity tends to decrease with age, but little is known about the relationship between having multiple sensory impairments and well-being in later life. Objective To examine associations between concurrent multisensory impairments and aspects of well-being and mental health, namely quality of life and depressive symptoms. Design, Setting, and Participants Cross-sectional analysis of participants in the English Longitudinal Study of Aging wave 8 (May 2016 to June 2017). This is a representative sample of free-living English individuals 52 years and older. Analysis began April 2018. Main Outcomes and Measures Linear and logistic regression models were used to assess the association of self-reported concurrent impairments in hearing, vision, smell, and taste with quality of life (0-57 on the 19-item CASP-19 scale; Control, Autonomy, Self-realization and Pleasure) and depressive symptoms (≥4 items on the 8-item Centre for Epidemiologic Study Depression Scale). Results Using a representative sample of 6147 individuals, 52% (weighted) were women (n = 3455; unweighted, 56%) and the mean (95% CI) age was 66.6 (66.2-67.0) years. Multiple sensory impairments were associated with poorer quality of life and greater odds of depressive symptoms after adjustment for sociodemographic characteristics, lifestyle factors, chronic conditions, and cognitive function. Compared with no sensory impairment, quality of life decreased linearly as the number of senses impaired increased, with individuals reporting 3 to 4 sensory impairments displaying the poorest quality of life (-4.68; 95% CI, -6.13 to -3.23 points on the CASP-19 scale). Similarly, odds of depressive symptoms increased linearly as the number of impairments increased. Individuals with 3 to 4 senses impaired had more than a 3-fold risk of depressive symptoms (odds ratio, 3.36; 95% CI, 2.28-4.96). Conclusions and Relevance In this cross-sectional study, concurrent sensory impairments were associated with poorer quality of life and increased risks of depressive symptoms. Therefore, assessing and managing sensory impairments could help improve older adults' well-being.
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Affiliation(s)
- Ann E M Liljas
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Amy Jones
- Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Dorina Cadar
- Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Andrew Steptoe
- Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Camille Lassale
- Department of Behavioural Science and Health, University College London, London, United Kingdom.,Epidemiology and Public Health Program, Hospital del Mar Medical Research Institute, Barcelona, Spain
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Liljas AEM, Walters K, de Oliveira C, Wannamethee SG, Ramsay SE, Carvalho LA. Self-Reported Sensory Impairments and Changes in Cognitive Performance: A Longitudinal 6-Year Follow-Up Study of English Community-Dwelling Adults Aged ⩾50 Years. J Aging Health 2018; 32:243-251. [PMID: 30522390 PMCID: PMC7221867 DOI: 10.1177/0898264318815391] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: To investigate the influence of single and dual sensory impairments prospectively on cognition in adults aged ⩾50 years. Method: Community-dwelling English adults (n = 4,621) were followed up from 2008 to 2014. Self-reported hearing and vision were collected in 2008. Change in cognitive performance on working memory and executive function between 2008 and 2014 was evaluated. Results: Compared with good hearing and good vision, respectively, poor hearing and poor vision were associated with worse cognitive function (hearing: unstandardized coefficient B = 0.83, 95% Confidence Interval [CI] = [0.29, 1.37]; vision: B = 1.61, 95% CI = [0.92, 2.29] adjusted for age, sex, baseline cognition). Compared with no sensory impairment, dual sensory impairment was associated with worse cognition (B = 2.30, 95% CI = [1.21, 3.39] adjusted for age, sex, baseline cognition). All associations remained after further adjustment for sociodemographic characteristics, lifestyle factors, chronic conditions, falls, mobility, depression, and lack of companionship. Discussion: The findings are important as age-related sensory impairments are often preventable or modifiable, which may prevent or delay cognitive impairment.
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Wettstein M, Wahl HW, Heyl V. Four-year reciprocal relationships between personality and functional ability in older adults with and without sensory impairment: focus on neuroticism and agreeableness. Aging Ment Health 2018; 22:834-843. [PMID: 28447472 DOI: 10.1080/13607863.2017.1318259] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Personality traits have been found to influence health and functional ability (FA) via multiple pathways. However, personality traits may also change in reaction to constraints in FA, particularly in more vulnerable individuals with high risk of decline in independent functioning in daily life (e.g. older adults with sensory impairment). Therefore, conceptually anchored in the World Health Organization's International Classification of Functioning, Disability and Health (ICF model), this study investigated reciprocal relationships between personality, focusing on neuroticism and agreeableness, and indicators of FA (i.e. activities of daily living and subjective autonomy) as well as the potentially moderating role of sensory impairment status. METHOD The study sample consisted of 387 older adults (mean age at T1: M = 82.50 years, SD = 4.71 years) who were either sensory impaired (SI; i.e. visually or hearing impaired) or sensory unimpaired (UI). A total of 168 individuals were reassessed four years later. RESULTS Depending on sensory status, personality acted both as predictor and as outcome of FA. Neuroticism was more strongly related with later FA outcomes in SI than in UI individuals. FA variables, in turn, were significant predictors of later neuroticism in UI older adults only and of later agreeableness in SI individuals only. CONCLUSION These findings suggest that the late-life personality-FA interplay needs to be considered bidirectional, and the direction of associations varies systematically as a function of sensory impairment status.
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Affiliation(s)
- Markus Wettstein
- a Department of Psychological Aging Research , Heidelberg University , Germany
| | - Hans-Werner Wahl
- a Department of Psychological Aging Research , Heidelberg University , Germany
| | - Vera Heyl
- b Institute of Special Education, University of Education , Heidelberg , Germany
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Liu E, Ng SK, Kahawita S, Andrew NH, Henderson T, Craig JE, Landers J. Ten-year all-cause mortality and its association with vision among Indigenous Australians within Central Australia: the Central Australian Ocular Health Study. Clin Exp Ophthalmol 2017; 45:348-356. [DOI: 10.1111/ceo.12880] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/07/2016] [Accepted: 11/13/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Ebony Liu
- Department of Ophthalmology; Flinders University, Flinders Medical Centre; Adelaide South Australia Australia
| | - Soo K Ng
- Department of Ophthalmology; Flinders University, Flinders Medical Centre; Adelaide South Australia Australia
| | - Shyalle Kahawita
- Department of Ophthalmology; Flinders University, Flinders Medical Centre; Adelaide South Australia Australia
| | - Nicholas H Andrew
- Department of Ophthalmology; Flinders University, Flinders Medical Centre; Adelaide South Australia Australia
| | - Tim Henderson
- Department of Ophthalmology; Alice Springs Hospital; Alice Springs Northern Territory Australia
| | - Jamie E Craig
- Department of Ophthalmology; Flinders University, Flinders Medical Centre; Adelaide South Australia Australia
| | - John Landers
- Department of Ophthalmology; Flinders University, Flinders Medical Centre; Adelaide South Australia Australia
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