Barriers to Vision Care for Nursing Home Residents

doi:10.1016/S1525-8610(04)70148-6

Journal of the American Medical Directors Association

Volume 2, Issue 1, January–February 2001, Pages 15-21

https://doi.org/10.1016/S1525-8610(04)70148-6 Get rights and content

Objective

To describe the prevalence of periodic eye examinations by eye professionals and to examine nursing facility resident characteristics associated with lack of periodic screening.

Design

Retrospective chart review.

Setting

Two Midwestern nursing facilities.

Participants

Between 1995 and 1997, 134 subjects aged 60 and older were recruited from two metropolitan nursing facilities.

Measurements

Nursing home charts were reviewed for: demographics, length of stay, date of eye examination, eye diagnosis, and visual acuity. Nursing assessments were used to obtain information about cognition, function, behavior, and the presence of Do Not Resuscitate or Do Not Hospitalize orders. The chart was reviewed for visual acuity, intraocular pressures, and the presence of eye pathology. Individuals who had not had eye examinations in the previous 2 years were screened by an ophthalmologist. This examination included external examination of the eye, fundoscopic examination, tonometry, and visual acuity with correction.

Results

Only 62 (46%) of the subjects had been seen by an eye care professional in the previous 2 years. Visual acuity information was available for 37/64 previously examined subjects. Of those with no eye examination in the previous 2 years (n = 72), visual acuity was obtained in 32 (44%) of subjects. New eye diagnoses were made in 64% (41/64). Logistic regression models with “eye examination within the past 2 years” as the dependent variable show that residents who do not desire hospital transfer are 80% less likely to have had an eye examination than those without this designation. Sex, age, length of stay, functional status, presence of severe dementia, behavior problems, or DNR orders do not change the likelihood that a resident would have been examined. Logistic regression models with “visual acuity measured” as the dependent variable show that residents with severe dementia are 12.6 times less likely to have acuity measured than those without dementia. Those with a length of stay in the facility less than 6 months are 10% less likely to have visual acuity measured.

Conclusions

This study does not confirm that barriers still exist in the provision of eye care to all nursing home residents, but the prevalence of such assessments remains low. Additional screening results in a substantial increase in the identification of treatable eye diseases. Contrary to the original hypotheses that patient characteristics that make testing difficult would provide a barrier or disincentive to vision testing, this study did not show statistical differences in the rates of vision screening for those with dementia, behavior problems, or severe functional impairment. Severe dementia does seem to affect the ability of the eye care specialist to gather subjective data such as visual acuity. It also demonstrates that vision screening does take place on nursing home residents with a broad range of cognitive and functional abilities, and this screening results in the diagnosis of many treatable eye conditions. Future efforts should be made to increase vision screening and treatment in the nursing home.

Section snippets

Background

Visual impairment increases with age and nursing home residents are three times more likely to have visual impairment and almost five times more likely to be legally blind than those living in the community.¹ The impact of visual impairment goes beyond difficulty with reading. Visual impairment in nursing home residents has been associated with decreased ability to perform basic activities of daily living and increased problems with social isolation.2, 3 Older individuals with visual impairment

Design

A retrospective chart review took place with examination of subjects not evaluated by an eye care professional in the previous 2 years.

Setting

Subjects were recruited from two Omaha metropolitan nursing facilities. Both of these facilities had contractual agreements with optometrists to provide on-site eye examinations for the residents.

Participants

Potential participants were identified by the nursing facility administrators, and all individuals residing in these facilities older than age 60 were invited to

Results

All residents of two metropolitan nursing facilities were invited to participate. Proxy consent and adult assent were given for 134 residents. Subjects mean age was 86 years, 85% were women, and 94% were white. Do Not Resuscitate orders were noted on the charts of 82% of subjects, but only 20% of subjects, all in one facility, did not want to be hospitalized for major illness. Dementia was prevalent, and 23% of subjects were classified by nursing staff as severely demented (ie, nursing staff

Conclusions

Visual impairment was very common in this sample of nursing home residents, 69% of whom had visual acuity worse than 20/40. This is slightly higher than the prevalence of visual impairment noted in other studies of nursing home residents, where 20 to 50% were visually impaired (acuity worse than 20/40) and 11 to 30% met criteria for legal blindness (acuity worse than 20/200.) 15, 16, 19 Cataract is the most common eye pathology in these nursing home residents, similar to that seen in the

Acknowledgments

The authors thank the patients who participated in this study and their families. The authors acknowledge the work of Joy Morton, BA, and Mark Eggleston, MD, who collected the data, Dale Mundy, BA, who assisted in data analysis, and Jackie Whittington for her technical assistance.

References (20)

R Klein et al.
The Beaver Dam Eye Study: Visual Acuity
Ophthalmology
(1991)
ME Tinetti et al.
Fall risk index for elderly patients based on number of chronic disabilities
Am J Med
(1986)
WG Whitmore
Eye disease in a geriatric nursing home population
Ophthalmology
(1989)
MS Marx et al.
Outcomes of cataract surgery in nursing home residents
Psychosomatics
(1995)
MS Marx et al.
The relationship between low vision and performance of activities of daily living in nursing home residents
J Am Geriatr Soc
(1992)
HE Resnick et al.
Windows to their world: The effect of sensory impairments on social engagement and activity time in nursing home residents
J Gerontol
(1997)
BW Rovner et al.
Depression, and disability in older people with impaired vision
A follow-up study. J Am Geriatr Soc
(1996)
M Mezey et al.
Consensus among geriatric experts on the components of a complete nursing-home admission assessment
Nurse Pract
(1992)
BC Corwin
Vision screening in nursing and retirement homes
J Am Optom Arch Am Acad Optom
(1972)
WJ Leslie et al.
A survey and proposal concerning visual care at the nursing home level
J Am Optom Assoc
(1974)

There are more references available in the full text version of this article.

Cited by (15)

Disparities in Vision Health and Eye Care
2022, Ophthalmology
Citation Excerpt :
Approximately 3.6% of the US elderly population live in nursing homes. Current literature shows that 63.8% to 73.0% of nursing home residents are affected by VI and blindness,37,39 and nursing home residents are 3 times more likely to have VI and 5 times more likely to experience blindness than individuals living in the community.40 According to a 2022 National Academies of Sciences, Engineering, and Medicine report, “sex is a multidimensional construct based on a cluster of anatomical and physiological traits that include external genitalia, secondary sex characteristics, gonads, chromosomes, and hormones,” whereas “gender is a multidimensional construct that links gender identity, which is a core element of a person’s individual identity; gender expression, which is how a person signals their gender to others through their behavior and appearance (such as hair style and clothing); and cultural expectations about social status, characteristics, and behavior that are associated with sex traits.”41
Prevalence of Vision Loss and Associations With Age-Related Eye Diseases Among Nursing Home Residents Aged ≥65 Years
2021, Journal of the American Medical Directors Association
Citation Excerpt :
Two reported acuities, and 3 reported vision impairment and blindness. Vision impairment or blindness ranged from 29%22 to 67%,20,21 and visual acuity less than 20/40 ranged from 61%16 to 74%.14 Our study showed the prevalence of vision impairment and blindness to be 63.4%.
To examine data from Delaware nursing homes to determine prevalence of age-related eye diseases (AREDs), vision impairment, and blindness and to compare the findings with the results of 11 US investigations of vision and eye health in nursing homes.
This is a cross-sectional, retrospective study of nursing home patients.
Twenty nursing homes in Delaware participated in the study, yielding comprehensive eye examination records for 2019 study participants.
Summary statistics and regression analyses.
The overall prevalence of vision impairment or blindness was 63.8% and was above 60% for each age, sex, and race category. Prevalence of vision impairment or blindness was 68.4% among patients with cataracts, 69.4% among patients with macular degeneration, 70.5% among patients with glaucoma, and 68.4% among patients with diabetic retinopathy. Prevalence of blindness was 14.1%. Among patients with AREDs, prevalence of blindness ranged from 15.0% for patients with cataracts to 22.6% for patients with diabetic retinopathy. When compared with other investigations, we found wide variation in vision and eye factors reported and wide variation in the prevalence of those factors. Only 4 studies diagnosed both AREDs and visual function. Seven studies reported AREDs, and 7 reported vision impairment and/or blindness. Vision impairment or blindness ranged from 29% to 67%; cataract ranged from 32% to 83%; macular degeneration ranged from 4.6% to 70.7%. Glaucoma ranged from 5.3% to 41.4%; diabetic retinopathy ranged from 1.7% to 3.1%.
Comprehensive eye examinations showed that vision impairment and blindness affected 63.8% of nursing home residents. Compared with other studies, there was a wide range of vision factors reported and wide variation in the prevalence of vision impairment or blindness and AREDs. This investigation suggests the importance of eye care in nursing homes and the importance of reporting standard vision and eye health factors to inform policy and practice.
Receipt of Eye Care Services among Medicare Beneficiaries with and without Dementia
2020, Ophthalmology
To examine the relationship between dementia status and receipt of eye care among US Medicare beneficiaries.
Retrospective, claims-based analysis.
A 20% representative sample of Medicare beneficiaries who received care between January 1, 2006, and December 31, 2015.
Dementia was identified from diagnosis codes documented in a beneficiary’s first 3 years of observed Medicare enrollment. Eye care visits were identified from provider specialty codes on each encounter claim. We used multivariable Cox proportional hazards regression models with time-varying covariates to compare the likelihood of receiving eye care between beneficiaries with and without dementia. All models were adjusted for potential confounders, including demographics, urban/rural residence, systemic health (Charlson Index), and ocular comorbidities.
Hazard ratio (HR) and 95% confidence interval (CI) for (1) being seen by any eye care provider (ophthalmologist or optometrist); (2) being seen by an ophthalmologist specifically; and (3) receiving cataract surgery (among beneficiaries with ophthalmologist encounters).
A total of 4 451 200 beneficiaries met inclusion criteria; 3 805 718 (85.5%) received eye care during the study period, and 391 556 (8.8%) had diagnosed dementia. Some 73.4% of beneficiaries diagnosed with dementia saw an eye care provider during the study period and 55.4% saw an ophthalmologist versus 86.7% and 74.0% of beneficiaries, respectively, without dementia diagnoses. Compared with those without dementia diagnoses, beneficiaries with diagnosed dementia had lower likelihood of seeing any eye care provider (adjusted HR, 0.69; 95% CI, 0.69–0.70) and were less likely to see an ophthalmologist (adjusted HR, 0.55; 95% CI, 0.55–0.55). Among the subset of beneficiaries who did see ophthalmologists, those with diagnosed dementia were also less likely to receive cataract surgery than beneficiaries without diagnosed dementia (HR, 0.62; 95% CI, 0.62–0.63) and less likely to receive a cataract diagnosis (18% vs. 82%).
US Medicare beneficiaries diagnosed with dementia are less likely to receive eye care than those without diagnosed dementia. Depending on visual acuity and functional status, this may have implications for injury prevention, physical and cognitive function, and quality of life. Further work is needed to identify barriers to receiving eye care, determine eye care services and settings that provide greatest value to patients with dementia, and implement measures to improve access to appropriate eye care.
Assessment of Visual Function in Institutionalized Elderly Patients
2009, Journal of the American Medical Directors Association
Citation Excerpt :
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.9,19–24 The present study differs from previous ones and is unique in 2 main respects.
To describe the visual function and ocular health of frail elderly patients institutionalized in a tertiary care university-affiliated geriatric hospital.
Retrospective file review.
A university-affiliated geriatric hospital.
440 patient files.
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.
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.
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.
Delivery of Vision Care in Nontraditional Settings
2007, Rosenbloom & Morgan's Vision and Aging
Delivery of Vision Care in Nontraditional Settings
2006, Rosenbloom & Morgan's Vision and Aging

View all citing articles on Scopus

Supported in part by University of Nebraska seed grant MGA/22-071-90201.

Presented, in part, at the 50th Annual Scientific Meeting of the Gerontological Society of America, Washington, DC, 1997.

View full text

Original StudiesBarriers to Vision Care for Nursing Home Residents

Objective

Design

Setting

Participants

Measurements

Results

Conclusions

Section snippets

Background

Design

Setting

Participants

Results

Conclusions

Acknowledgments

Ophthalmology

Am J Med

Ophthalmology

Psychosomatics

The relationship between low vision and performance of activities of daily living in nursing home residents

J Am Geriatr Soc

Windows to their world: The effect of sensory impairments on social engagement and activity time in nursing home residents

J Gerontol

Depression, and disability in older people with impaired vision

A follow-up study. J Am Geriatr Soc

Consensus among geriatric experts on the components of a complete nursing-home admission assessment

Nurse Pract

Vision screening in nursing and retirement homes

J Am Optom Arch Am Acad Optom

A survey and proposal concerning visual care at the nursing home level

J Am Optom Assoc

Original Studies
Barriers to Vision Care for Nursing Home Residents