Assessment of Visual Function in Institutionalized Elderly Patients
Article Outline
Objective
To describe the visual function and ocular health of frail elderly patients institutionalized in a tertiary care university-affiliated geriatric hospital.
Design
Retrospective file review.
Setting
A university-affiliated geriatric hospital.
Participants
440 patient files.
Measurements
The archived clinical files of patients from the long-term care beds of the Institut universitaire de gériatrie de Montréal, who had died between April 2000 and 2004 were reviewed. Pertinent medical and visual characteristics were extracted and entered into a database for analysis.
Results
The age of the patients ranged from 65 to 104 years. The major ocular conditions observed were cataract, pseudophakia, conjunctivitis-blepharitis, age-related macular degeneration, and glaucoma. Of the 231 patients referred for a partial or full eye examination, visual acuity was available in 178. Visual impairment was considered absent in 87 patients; mild in 52; moderate in 17; and 22 patients were legally blind. Of the 105 patients referred for a full eye examination, an evaluation of the refraction, visual acuity, and ocular health was possible in 89, irrespective of their cognitive status.
Conclusion
These data demonstrate that the vast majority of severely disabled elderly patients examined retained good visual acuity into advanced age. The most prevalent ocular conditions observed are treatable, thereby emphasizing the importance of regular eye care for the institutionalized frail elderly. The results clearly demonstrate that it is possible to perform a complete evaluation of visual function and ocular health in the elderly institutionalized patient, independent of age, cognitive status, or communication disorders.
Keywords: Dementia, frail elderly, long-term care units, visual examination
In 2001, 13% of the Canadian population was 65 years of age or older,1 a percentage expected to double by 2031.2 Similar statistics are found in many other developed countries.3 The aging of our population is further characterized by a more rapid increase of individuals aged older than 75 years, a feminization of the population living longer, and a shifting of the principal causes of morbidity and mortality toward chronic illnesses. Many elderly persons affected by these chronic diseases will eventually be institutionalized because of their functional dependency and the accompanying increased care required by their condition. Many of these patients also suffer from diseases affecting their cognitive and communication skills that may render the clinical evaluation more challenging.
Older persons experience several alterations of visual function,4 due primarily to the normal aging process. Aging, however, is also accompanied by an increased prevalence of ocular diseases. Consequently, many elderly will be affected by vision loss progressing to blindness, while others will suffer less severe visual dysfunction, impairing, nevertheless, their ability to function in an independent fashion,5, 6, 7 and diminishing both their autonomy and quality of life.
The ocular history of patients admitted to long-term care units is not necessarily well documented, unless a diagnosis of ocular pathology has already been made before admission. Furthermore, these patients do not necessarily receive a systematic or periodical eye examination unless a problem arises, such as the loss of their eyeglasses, the presence of a red eye, or a suspicion of vision loss. Recent studies have reported that a substantial number of elderly residents living in nursing homes often suffer some degree of visual impairment.8, 9 Furthermore, studies have shown that their quality of life is improved when visual functioning is improved through procedures such as optimizing refraction or cataract surgery.10, 11, 12, 13
Very few studies, however, have presented clinical data based on evaluations of vision performed on institutionalized elderly patients as part of their overall health care. The objective of the present study was to describe the visual health of elderly patients institutionalized in the long-term care units of a tertiary care university-affiliated geriatric hospital, based on data obtained from their medical files. This study will serve the dual purpose of describing the visual status of these patients, as well as showing the extent of visual care that can be offered to this frail elderly population.
Methods
Hospital Setting
The study was performed at the Institut universitaire de gériatrie de Montréal (IUGM). The IUGM is a 452-bed facility and includes services for long-term care (379 beds), acute care geriatrics (28 beds), and intensive rehabilitation (45 beds). Services are also offered through its outpatient clinics, day hospital, and day center to patients who do not reside within the hospital. All these units are staffed by an interdisciplinary team. Each patient has one primary family physician and also has access to a team of specialists as well as other health professionals.
File Review
The data presented here are based on archived clinical files of patients from the long-term care units of the IUGM, who passed away between April 2000 and April 2004. Approbation was obtained from the IUGM Ethics Committee before reviewing the files. A total of 440 files were available for review. Pertinent medical and visual characteristics were extracted from these files and entered into a database for analysis. Each patient's file was identified by a number only in the database; the code between this number and the patient's file was kept separate by the principal researcher.
Database
A portable Macintosh computer, with FileMaker Pro software (File Maker, Inc., Santa Clara, CA), was used for creating the database. The main categories of data entered in the database related to (1) patient demographics; (2) primary medical diagnosis and various diagnoses related to cognitive, behavioral, communication, or cardiovascular disorders; (3) subjective visual symptoms and referral for an eye examination; and (4) all data related to vision from the general, ophthalmological, or optometric files.
Results
The sample size included 318 females (mean age ± SD: 87.4 ± 7.2 years) and 122 males (83.3 ± 7.5 years), as shown in Figure 1. Most patients were White, comprising 89.8% of the sample.
Fig. 1.
Age and sex characteristics of the study population. The white and grey bars represent data for men and women, respectively. The number atop each bar indicates the number of subjects included in each age category.
The prevalence of dementia and communication disorders in the study population (n = 440) were 87.0% (n = 383) and 44.8% (n = 197), respectively. The type of dementia, from the most to the least prevalent, were Alzheimer, vascular, mixed (Alzheimer + vascular), parkinsonian, and Lewy body. The main communication disorder was aphasia. A proportion of 41.4% (n = 182) of the population had both cognitive and communication disorders, and 76.8% (n = 338) had behavioral problems. Cardiovascular disorders were found in 87.5% (n = 385). Of all patients referred for an eye examination (n = 231), 89.2% (n = 206) had dementia, 38.5% (n = 89) had a communication disorder, and 35.9% (n = 83) had dementia as well as a communication disorder. A further 77.9% (n = 180) had a behavioral problem and 89.2% (n = 206) at least one cardiovascular pathology.
Of the 231 patients referred for eye care, 126 and 33 were seen in either ophthalmology or optometry respectively, and 72 were seen in both services. Only patients seen in optometry received a full visual examination. Patients seen in ophthalmology received an evaluation oriented specifically toward ocular pathology. Visual acuity (VA) was obtained in 77.1% (n = 178) of those patients. These data are presented in Figure 2 in minutes of arc of the distance VA measured in the better-seeing eye. The filled diamonds identify patients for whom VA was measured after an optimized refraction was performed. The empty squares show the VA taken with the patients' current ophthalmic correction. For most of those patients, no refraction was performed because they were seen in ophthalmology, or the complete evaluation could not be realized due to a lack of cooperation. The horizontal line at the bottom of the graph represents a VA of 20/20 (6/6), whereas the dashed line indicates a level of VA of 20/40 (6/12). The regression line (r = 0.189; P = .092) drawn through the data points representing best VA after refraction revealed that VA did not vary with age.
Fig. 2.
Visual acuity as a function of age. Data showing VA in minutes of arc (minarc) as a function of age for all subjects in whom VA was obtained. Each datum point represents the distance VA measured in the best seeing eye of each subject. The filled diamonds represent the optimized VA measured after an ocular refraction was performed whereas the empty squares represent the habitual VA for patients in whom an ocular refraction was not performed. Data points for VA inferior to 20/200 (6/60) are not presented in this graph. The horizontal full and dashed lines at the bottom of the graph represent a level of VA of 20/20 (6/6) and 20/40 (6/12), respectively. Data points contained between these 2 lines indicate subjects without visual impairment based on their level of VA. The regression line has been drawn through the filled diamonds only, to indicate how corrected VA varies as a function of age. Data points for optimized visual acuities inferior to 20/200 (6/60) have been included in this regression line, even if they are not presented in the graph.
The VAs obtained were classified into 4 categories of visual impairment based on existing data in the literature as well as definitions of low vision (<20/70 [<6/21] in the best eye) and legal blindness (≤20/200 [≤6/60] in the best eye) in the province of Quebec.4 The visual field criterion was not taken into account to define low vision and legal blindness in this report. The VA categories, together with the number of patients comprised within each category, are presented in Table 1. The principal causes of severe visual impairment and blindness in this study were age-related macular degeneration (ARMD) (n = 14) and glaucoma (n = 7).
Table 1. Category of Visual Impairment in the Study Population
| Category of Visual Impairment | Visual Acuity Level | n |
|---|---|---|
| None | ≥20/40 (≥6/12) | 87 |
| Mild | <20/40(<6/12)to≥20/70(≥6/21) | 52 |
| Moderate | <20/70(<6/21)to>20/200(>6/60) | 17 |
| Legal blindness | ≤20/200(≤6/60) | 22 |
The principal ocular conditions in the study population (n = 440) were cataract in 43.6% (n = 192), pseudophakia in 25.5% (n = 112), blepharitis/conjunctivitis in 22.0% (n = 97), ARMD in 15.5% (n = 68), and glaucoma in 13.9% (n = 61). Among the patients referred for an eye examination (n = 231), the main ocular diagnoses were cataract in 63.2% (n = 146), pseudophakia in 33.8% (n = 78), blepharitis/conjunctivitis in 29.4% (n = 68), ARMD in 26.0% (n = 60), and glaucoma in 22.9% (n = 53). The mean intraocular pressure (IOP) for all patients without glaucoma and in whom this measurement was obtained (n = 121) was 15.8 mm Hg (SD: 2.1 mm Hg) and 15.7 mm Hg (SD: 2.2 mm Hg) for the right and left eye, respectively. The averaged IOP for both eyes of each subject was plotted as a function of age. A regression line through all data points revealed that the IOP did not vary with age (r = 0.02; P = .813) in this elderly population.
Among the 385 patients with cardiovascular disease, 16.4% (n = 63) had ARMD and 14.3% (n = 55) had glaucoma. Among the 228 patients having dementia of the Alzheimer type (DAT), 13.6% (n = 31) had ARMD and 12.7% (n = 29) had glaucoma. Among the 231 patients referred for an eye examination with cardiovascular disease (n = 203), 27.6% (n = 56) had ARMD and 23.6% (n = 48) had glaucoma. Among the 231 patients referred for an eye examination with DAT (n = 117), 23.1% (n = 27) had ARMD and 22.2% (n = 26) had glaucoma.
Of all patients referred to optometry for a complete visual examination (n = 105), 87.6% (n = 92) had cognitive deficits. Figure 3 presents the Mini-Mental State Examination (MMSE) scores for all 105 patients. The MMSE is a brief, quantitative test for screening cognitive impairment in elderly patients.14 The MMSE scores have been arbitrarily classified in 7 different stages, each comprising 5 score units except for the first category which comprised scores of zero only. It was possible to perform refraction, a measurement of VA as well as an assessment of ocular health in 84.8% (n = 89) of the patients, independent of their MMSE scores. For the patients in whom both the VA and a refraction could be performed (n = 92), the results indicated that VA could be improved in 58.7% (n = 54), whereas the other 41.3% (n = 38) did not demonstrate any improvement. Considering all acuities as a whole, on average, the VA could be improved from about 20/90 to 20/40 (6/27 to 6/12) in those 54 patients.
Fig. 3.
MMSE scores of patients seen in optometry. MMSE scores for all patients having been referred in optometry for a full eye examination (n = 105). The MMSE scores have been divided in 7 different categories as indicated on the abscissa. The filled bars represent subjects (n = 89) for whom it was possible to do a full eye examination including refraction, VA, and ocular health. The empty bars represent the remaining subjects (n = 16) for whom only 2 or 1 of these 3 evaluations could be performed. The number atop each bar represents the number of subjects in each MMSE category.
Discussion
The data reported in this study are in agreement with current demographics of institutionalized elderly showing that our population comprised mainly the oldest segment of the elderly population and most were women. It is also well documented that dementia is prevalent in this elderly population, affecting 1 of 3 persons over 85 years of age.15 Considering that dementia is often a major reason for institutionalization in long-term care units, it is not unexpected that 87.0% of our population was affected by this neurodegenerative disorder. The data further show that this population is also affected by a high prevalence of communication and behavioral disorders.
Several studies have published data on the necessity of eye care services in the elderly residing in nursing homes or long-term care units, and the fact that this population is under-serviced. Many of these studies have presented data based on questionnaires16 or the results of specific tests performed in these institutions for the purpose of investigating the visual needs of these patients.8, 17 However, some of these studies have excluded patients with more severe forms of dementia.8 Two studies have published data derived from optometric services provided in nursing homes.12, 18 Other studies have reported data based on eye examinations provided to nursing home residents at the time of the study, in order to describe their visual status and the need for eye care.9, 19, 20, 21, 22, 23, 24
The present study differs from previous ones and is unique in 2 main respects. First, the objective was not to evaluate the need for eye care services in long-term care units, but rather to present the visual status of the frail elderly population and extent of eye care services that can be offered to them in a clinical setting. Second, the population evaluated is characterized by a high prevalence of cognitive, behavioral, and communication disorders that may render the examination more challenging.
An important result is that most elderly patients preserved very good VA with age. The regression line through data points obtained after optimization of the VA through a refraction (Figure 2) indicates that VA is not affected significantly between 65 and 104 years of age; most patients retaining VA better than 20/40 (6/12) in advanced age. These findings are notable since they underline not only the importance of providing eye care services to these patients but also to conduct the examination with a view toward optimizing VA to its full potential through an adapted and carefully driven refractive examination. For patients in whom an ocular refraction could be performed (n = 92) and VA was seen to improve (n = 54), the group-averaged data indicated that VA increased from about 20/90 to 20/40 (6/27 to 6/12) or more than 5 lines of acuity on a regular Snellen chart. For some patients, it was not possible to measure VA both before and after the refraction. The averaged VA was about 20/300 (6/90) and 20/60 (6/18) in patients for whom it could be measured only before versus only after refraction, respectively. The better acuity level post versus prerefraction suggests that it is possible to improve VA in a larger proportion of patients.
Overall, 87.6% (n = 92) of the 105 patients referred for a full eye examination had dementia. However, it was still possible to measure VA, perform an ocular refraction, and evaluate ocular health in 84.8% (n = 78) of these 92 patients, independent of their MMSE scores. In 12 patients, only 2 of these tests could be performed and 1 test in another 2 patients. These data clearly demonstrate that a periodical visual examination can be advantageous for patients institutionalized in long-term care units, and certainly suggests that, in the presence of any signs or symptoms of visual problems, a full eye examination should be performed or at least attempted. The MMSE scores should be taken into consideration, but should not be seen as an obstacle to the delivery of eye care services. Moreover, the data indicate that the most prevalent eye diseases encountered in these patients are treatable to some extent and are likely to either improve or preserve vision and quality of life in these situations.
The study population was characterized by a high prevalence of cardiovascular diseases and dementia, mainly of the Alzheimer type. Reports in the literature have suggested that ARMD and glaucoma have multiple etiologies, including vascular factors.25, 26 On the other hand, several studies have reported an association between DAT and glaucoma27, 28 as well as ARMD.29 Our data likewise revealed that a proportion of patients with cardiovascular diseases also had ARMD and glaucoma, and that many patients with DAT also had glaucoma or ARMD. Although these data are interesting and seem to give support to previous reports, our sample size is likely not large enough to confirm these findings.
Most patients with dementia will eventually suffer from impaired autonomy and increased dependency for their activities of daily living. It is therefore important to offer them all treatment modalities likely to help prolong their autonomy and independence. The present data clearly indicate that they can benefit from regular eye care services to preserve and improve their vision. This issue should not be underrated, since vision is a very important sensory modality, particularly in those patients bed or wheelchair bound who are already limited in their activities. Furthermore, these patients are often affected in their ability to express their symptoms or needs and the present data have shown that a visual examination can be provided irrespective of age, MMSE scores, or communication disabilities.
Conclusion
In conclusion, this study presents unique and novel data emphasizing the importance and pertinence of providing complete eye evaluation and eye care services to the frail elderly population, despite the presence of significant obstacles such as dementia and/or communication disorders.
Acknowledgments
The authors thank Johanne Gosselin, chief archivist at the Institut universitaire de gériatrie de Montréal, for her help with handling the clinical files, and Denis Latendresse for his help with the Filemaker Pro software.
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This work was supported by grants from the Institut Universitaire de Gériatrie de Montréal-Comité Aviseur pour la Recherche Clinique, the Fondation Caroline-Durand, and the Canadian Optometric Education Trust Fund. H.K. is the recipient of a Clinician/Scientist award from the Institute of Aging of the Canadian Institutes of Health Research.
PII: S1525-8610(08)00259-4
doi:10.1016/j.jamda.2008.07.005
© 2009 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.
