Current Eye Research, 2014; 39(3): 232–238 ! Informa Healthcare USA, Inc. ISSN: 0271-3683 print / 1460-2202 online DOI: 10.3109/02713683.2013.838973
ORIGINAL ARTICLE
Impact of Visual Impairment on Vision-Specific Quality of Life among Older Adults Living in Nursing Home Mahesh Kumar Dev1, Nabin Paudel1,3, Niraj Dev Joshi1, Dev Narayan Shah1 and Shishir Subba2 1
Department of Ophthalmology, B. P. Koirala Lions Center for Ophthalmic Studies, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal, 2Central Department of Psychology, Tribhuvan University, Kathmandu, Nepal, and 3Department of Optometry and Vision science, The University of Auckland, Auckland, New Zealand
ABSTRACT
Keywords: : Blindness, kathmandu, nursing home, prevalence, quality of life, visual impairment
INTRODUCTION
20 14
Background: Visual impairment (VI) has a significant negative impact on quality of life (QoL) amongst older people living in nursing homes. The purpose of this study was to determine the prevalence of VI and blindness and to explore the association between severity of VI and vision-specific QoL among older people living in nursing homes of Kathmandu, Nepal. Methods: This cross-sectional study involved 158 residents aged 60 years or older residing in seven nursing homes of Kathmandu Valley, Nepal. Near acuity, presenting and the best corrected distance visual acuity (VA) were assessed in each eye and considered in the better eye after adequate refraction. A complete anterior and posterior segment examination was carried out. Face-to-face interviews were conducted using a 57-item Nursing Home Vision-Targeted Health-Related Quality of Life (NHVQoL) questionnaire. Results: The mean age of residents was 75.60 7.12 years and the majority were female (66.46%). The prevalence of VI and blindness was 45.57% and its leading cause was cataract, which was followed by age-related macular degeneration, corneal opacity, glaucoma and macular scar. The mean composite score of NHVQoL questionnaire was 52.22 12.49. There was a consistent overall deterioration in the mean composite score as well as each subscale score of NHVQoL questionnaire with a worsening of VA. Conclusion: VI and blindness are highly prevalent among older people living in nursing homes. VI has a significant negative impact on vision-specific QoL. Vision-specific QoL is reduced, and the reduction in the QoL bears a positive association with severity of VI among older people living in nursing homes.
Major causes of irreversible blindness such as retinal diseases, glaucoma, age-related macular degeneration (ARMD) as well as reversible causes like cataract are common in nursing homes. It is vital that vision care not be ignored in this population.1,12,13 VI has significant and deleterious impact on quality of life (QoL) and reduces vision-related QoL.2,3,5,6,14 Vision-related QoL is the present visual status and the
The prevalence of visual impairment (VI) and blindness is higher among older people living in nursing homes than that of the same base population living outside nursing homes because the former often do not have the same access to health care as do people living at home.1–12
Received 5 September 2012; revised 18 July 2013; accepted 23 August 2013; published online 21 October 2013 Correspondence: Mahesh Kumar Dev, B. Optom, B. P. Koirala Lions Center for Ophthalmic Studies, Department of Ophthalmology, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal. Tel: 977-9841633280. Fax: 977-1-4720142. E-mail: maheshdev2002@ gmail.com; [email protected]; [email protected]
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Impact of Visual Impairment on Quality of Life limitations in daily living activities like personal hygiene, communication, self-care, social skills, mobility, safety etc. as perceived by the subjects. Visual function is important for an optimal orientation in functional and social life and has effects on physical, psychological, mental and emotional well-being.1,14–18 Impaired vision significantly reduces activities associated with participation in society and religion, mobility, recreation and daily living etc.1–3,15,16 Vision loss in later life contributes to physical activity limitations, reduction in independent mobility, imbalance, risk of hip fractures, mortality and the need for community and/or family support.2,3,7,16,18 VI and blindness are major forms of disability in individuals living in nursing homes and these affect vision-specific functioning and socio-emotional aspects of daily living.1,2–4,16–20 Nursing home residents may be more prone to depression and other types of mental health problems due to impaired vision.2 Psychosocial adaptation status is significantly associated with vision-specific QoL, including the domains of mental health symptoms due to impaired vision. There is a little information about the impact of VI on vision-specific QoL as the majority of researches have been limited to the prevalence of VI and blindness but little attention has been paid to visionrelated QoL.3 The purpose of this study was to determine the prevalence of VI and blindness and to explore the relationship between severity of VI and vision-specific QoL. To the best of our knowledge, to date, no such study on impact of VI on vision-specific QoL among older people living in nursing homes has been done in Nepal.
MATERIALS AND METHODS Participants This was a descriptive, cross-sectional and institutionalized study conducted among older people living in seven different nursing homes of Kathmandu Valley, Nepal. The participants included in this study are among our earlier study population, which was primarily aimed at determining the prevalence of VI and blindness in nursing home residents.1 There were a total of 364 residents aged 60 years or older who performed complete ophthalmological examination, which included distance and near visual acuity (VA) assessment, refraction and a complete external and internal ocular examination; however, the interviews required for this study were completed only by 158 of those participants. There were various reasons for our inability to include all participants from our earlier study: some of them had disabilities and diseases like intellectual disabilities (6), Down’s syndrome (2), Alzheimer’s disease (2), hearing impairment (8), !
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inability to speak and listen (25) and bed ridden due to stroke (14) which affected their ability to provide proper responses, but a large number of residents (149) were excluded as they were not interested and hence did not give consent to this study. The information on various diseases and disorders of the residents was based on their medical records. For the enrollees of this study, informed consents were obtained both from the administrator of the nursing homes and from the residents themselves. Participants were eligible to participate if they agreed and were capable of answering questions about their vision and daily living activities. The results in this study are based on the 158 residents only who met our eligibility criteria. The institutional review board at the Institute of Medicine, Tribhuvan University, approved the study protocol, and the study followed the tenets of the Declaration of Helsinki. Enrollees’ particulars including age, sex, marital status, educational status and ethnicity were noted. Ethnicity classification was applied as per the Central Bureau of Statistics of Nepal.
Assessment Presenting distance VA was assessed with the Snellen chart at 6-metre distance in non-standardized outdoor illumination and near acuity with the Lighthouse Near Visual Acuity Card. Refraction was performed by an optometrist, and the best corrected distance VA was considered in the better eye. A complete anterior and posterior segment examination was carried out in all the residents by a team of optometrists and ophthalmologists. Anterior segment evaluation was carried out with a torch light and a handheld portable slit lamp. Posterior segment evaluation was done with a direct ophthalmoscope as well as a head-mounted binocular indirect ophthalmoscope. Intraocular pressure was measured with a handheld Perkins applanation tonometer.
Quality of Life Vision-related QoL was assessed by conducting faceto-face interview using a 57-item Nursing Home Vision-Targeted Health-Related Quality of Life (NHVQoL) questionnaire.14 The NHVQoL questionnaire, designed specifically for nursing home residents, was used to assess vision-targeted healthrelated QoL.2,3,14,19,20 The item design and question structure is based on the National Eye Institute-Vision Function Questionnaire. The questionnaire was designed to evaluate the impact of VI and eye disease on QoL and mental health in older nursing home residents and to assess the effectiveness of psychosocial and eye care interventions in nursing homes.
234 M. K. Dev et al. This instrument consists of nine subscales: general vision (6 items), reading (3 items), ocular symptoms (9 items), mobility (7 items), psychological distress (10 items), activities of daily living (6 items), social activities and hobbies (8 items), adaptation and coping (2 items) and social interaction (6 items). The NHVQoL was translated to Nepali and back translated to English to check the consistency in meaning. Few modifications were made in questions to make it suitable for Nepalese culture. Face validity was done with bilingual subjects to ensure that both versions provided the same response with the same score. Cronbach’s alpha of the sample of nine subscales score of NHVQoL was 0.801, which states good internal consistency and reliability of test scores. The face-to-face interviews were conducted by the primary author himself who was working with a psychologist and received training on research methodology and questionnaire administration. Few other assistants were trained by the author to help him in administering questionnaire. The agreement in the score values was compared between the interviewers randomly. There was a high agreement between the scores obtained from different interviewers. The NHVQoL questionnaire was scored according to the scoring algorithm NHVQoL subscales on a scale ranging from 0 to 100, with 0 indicating the lowest level of function (representing severe disability) and 100 indicating the highest level of function (representing
no disability).2,3,14,19,20 A high score indicates high QoL and a low score indicates poor QoL.
Statistical Analysis Recorded data were analyzed using Statistical Package for Social Sciences version 17.0 (SPSS, Chicago, IL, USA) and Microsoft Excel version 2010 (Redmond, WA, USA).
RESULTS Demographics of Study Participants Table 1 presents demographic characteristics. Mean age of the residents was 75.60 7.12 years (range, 60– 102 years). The majority of residents (43.67%, 69) were in the age range of 70–79 years. There was no statistically significant difference between the mean age of male (76.00 7.64 years) and female residents (75.40 6.88 years) (t-test, p = 0.66). The vast majority (66.46%, 105) were female residents and most were widowed (57%). Most of the enrollees (46.20%, 73) were advantaged Janajatis and the least (1.27%, 2) were of the Dalit category by ethnicity.
Near Acuity Mean presenting near acuity was 14 N (SD 2.21), and the best near acuity after appropriate near correction
TABLE 1 Demographics of the study enrollees (based on the best corrected distance VA). Severity of visual impairment, N (%) Characteristics Age range (years) 60–69 70–79 80–89 90–99 4100 Sex Male Female Race/ethnicity Upper caste Advantaged Janjatis Non-Dalit Terai Disadvantaged Janjatis Dalit Education Illiterate Simple read and write Primary school Secondary school
No. in each group N (%) 158 (100) 31 69 56 1 1
(19.62) (43.67) (35.45) (0.63) (0.63)
53 (33.54) 105 (66.46)
No VI 86 (54.43)
Moderate VI 46 (29.11)
Severe VI or worse 26 (16.46)
13 (41.94) 15 (21.74) 17 (30.36) – 1 (100.00)
3 (9.68) 9 (13.04) 14 (25.00) – –
27 (50.94) 59 (56.19)
16 (30.19) 30 (28.57)
10 (18.87) 16 (15.24)
15 45 25 1
(48.39) (65.22) (44.64) (100.00) –
54 73 3 26 2
(34.18) (46.20) (1.90) (16.46) (1.27)
29 46 2 9
(53.70) (63.01) (66.67) (34.62) –
19 16 1 9 1
(35.19) (21.92) (33.33) (34.62) (50.00)
6 (11.11) 11 (15.07) – 8 (30.77) 1 (50.00)
127 27 3 1
(80.38) (17.09) (1.90) (0.63)
63 20 2 1
(49.61) (74.07) (66.67) (100.00)
39 (30.71) 6 (22.22) 1 (33.33) –
25 (19.69) 1 (3.71) – –
VI: visual impairment. The percentage values in parentheses in the section ‘‘No. in each group’’ is out of the total 158 residents; however, the percentage values in parentheses for ‘‘severity of visual impairment’’ is by considering numbers in each subgroup as 100%. For instance, in the sex category, there were 53 males which is 33.54% of 158 residents and among them 27, which is 50.94% of 53 males, were normal or without VI. Current Eye Research
Impact of Visual Impairment on Quality of Life was 8 N (SD 1.53). The difference was statistically significant (Wilcoxon Signed Ranks Test, p50.05).
VI and Blindness Quantification of presenting and the best corrected distance VA was expressed in Snellen notation and was followed as that established by the World Health Organization and used in the International Classification of Diseases.21 According to this, VA was classified as: normal with no VI (VA 6/18), moderate VI (VA56/18–6/60), severe VI (VA56/60– 3/60), legally blind (VA53/60 – perception of light) and totally blind (no perception of light).21 As there were very few residents in legally blindness and totally blindness groups, these groups were merged with severely VI group and jointly considered as severely VI or worse group. Considering the presenting VA in the better eye, the prevalence of VI and blindness was 60.76%; but after appropriate refractive correction, the prevalence was reduced to 45.57% (Table 2). Refractive correction alone reduced the prevalence of VI and blindness by 15.19%, which was statistically significant (McNemar Test, p50.05). Cataract was the leading cause of non-refractive VI and blindness (47.22%) (Aphakia and pseudophakia were also included in cataract). Cataract was followed by ARMD (9.82%), corneal opacity (8.33%), glaucoma
TABLE 2 Presenting and best corrected distance VA in the better eye. Acuity (Snellen notation)
Presenting After correction N (%) N (%)
6/18 (normal/near normal) 62 56/18–6/60 (moderate VI) 65 56/60–NPL (severe VI or worse) 31 Total 158
(39.24) (41.14) (19.62) (100)
86 46 26 158
(54.43) (29.11) (16.46) (100)
VA: visual acuity. VI: visual impairment. NPL: no perception of light.
(7.0%), macular scar (6.73%), retinal degeneration and dystrophy (5.41 %) and others. There was no statistically significant difference between the prevalence of VI and blindness among upper caste (46.30%), advantaged Janajatis (36.99%), non-dalit Terai (33.33%) and the disadvantaged Janajatis (65.39%) (analysis of variance; ANOVA, p = 0.679).
Vision-Specific QoL The mean overall (composite) score of NHVQoL questionnaire was 52.22 12.49. Vision-specific QoL was reduced among nursing home residents. The reduction in vision-specific QoL score showed a negative correlation with the severity of presenting distance VI (Pearson’s R = –0.579) and was statistically significant (p50.05) (Figure 1). Table 3 presents mean score and each subscale score of NHVQoL instrument. The mean composite score of NHVQoL questionnaire decreased as the severity of presenting distance VI increased (worsening of VA). There was a gradual deterioration of scores from normal residents (i.e. having no VI) to moderate VI, severe VI or worse and accordingly QoL decreased gradually with increase in the severity of presenting distance VI. This was statistically significant between normal residents with no VI and residents with moderate VI (ANOVA, p50.05, 95% CI of the difference 5.34–13.61), between normal and severe VI or worse groups (ANOVA, p50.05,95% CI of the difference 4.91–19.22) and also between moderate VI and severe VI or worse groups (ANOVA, p50.05,95 % CI of the difference 3.76–14.94).
Association between Severity of VI and Subscales Score of NHVQoL Table 3 presents the relationship between presenting distance vision impairment and vision-specific QoL.
FIGURE 1 Relationship between severity of presenting distance VI and mean score of NHVQoL questionnaire. !
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236 M. K. Dev et al. TABLE 3 Mean score and each subscales score of NHVQoL questionnaire (based on presenting VA). NHVQoL indicators
Mean score
Composite score Mean (SD) General vision Reading Ocular symptom Activities of daily livings Mobility Social activities/hobbies Psychological distress Adaptation/coping Social interaction
52.22 43.39 62.39 41.38 64.85 63.00 64.10 37.28 40.36 58.83
(12.49) (22.11) (24.27) (11.74) (18.18) (19.08) (22.46) (23.41) (22.57) (17.22)
Normal 58.05 48.75 71.28 44.10 71.46 72.00 76.53 36.96 64.43 41.00
Moderate VI
(9.14) (22.51) (21.29) (12.62) (15.57) (14.13) (15.19) (24.72) (25.41) (15.67)
48.57 35.86 56.30 38.66 62.03 57.83 54.42 38.36 56.36 42.00
(9.43)* (15.52)* (21.73)* (9.99)* (15.93)* (18.52)* (15.03)* (20.88) (18.50) (12.39)*
Severe VI or worse 41.03 29.50 46.00 40.00 50.00 45.50 42.00 34.50 47.50 37.50
(11.89)* (20.56)* (23.98)* (8.54) (16.43)* (12.51) (24.96)* (23.16) (19.29) (18.87)
F value 21.12 6.77 10.38 3.08 12.68 21.19 30.83 1.20 1.34 10.21
NHVQoL: Nursing Home Vision-Targeted Health-Related Quality of Life. VI: visual impairment. *Indicates significant differences considering the normal group as a reference group.
There was a consistent overall deterioration in each subscale score of NHVQoL questionnaire with a worsening of distance vision except for ocular symptoms, psychosocial distress and adaptation subscales. There was a statistically significant difference in the mean score among normal, moderate VI and severe VI or worse groups in all subscales (ANOVA, p50.05) but not ocular symptoms, psychosocial distress and adaptation subscales.
DISCUSSION This study was conducted to determine the prevalence of VI and blindness and explore its impact on vision-specific QoL. The prevalence of VI and blindness (60.76%) at the presenting VA and even after refractive correction (45.57%) was significantly higher in comparison to the published data.10,12,13 This may be due to a lack of availability of services, but could be due to poor utilization of accessible eye care services by nursing home residents compared to people living at their own homes. It may be also because residents commonly do not wear spectacles even though they have them and they believe that aged people do not personally benefit from treatment intended to improve vision. We accept that our results might have been biased somehow toward higher prevalence of VI and blindness because the residents with whom interviews could not be conducted had slightly better VA (statistically non-significant) than the residents with whom interviews were conducted. The prevalence of VI and blindness was almost similar to that of the study by Owsley et al.4 Cataract was the leading cause of non-refractive VI and blindness (47.22%) followed by ARMD (9.82%), corneal opacity (8.33%), glaucoma (7.0%) and macular scar (6.73%). This was consistent with published data.1,4,12,13 The reasons for cataract to be the leading cause may be inadequate eye care services, high prevalence of mature cataract and inappropriately low use of cataract surgery. The major reason for the low use of cataract surgery among nursing home
residents of Nepal is due to lack of eye care professionals who routinely serve nursing home residents. Ocular health is still not included in the national health policy of the country. Neither the government nor any concerned group has paid any interest toward the routine and comprehensive eye examination of nursing home residents. The study conducted by Friedman et al.17 highlights that multiple obstacles prevent nursing home residents from undergoing cataract surgery. An important barrier was the lack of willingness of family members, guardians and the residents themselves to consent to surgery. Besides these, cultural beliefs regarding surgical interventions, lack of routine eye care services and transportation are some of barriers to access cataract surgery.17 Hence, it is essential to create awareness that cataract surgery is life enhancing and it improves the QoL. The programs to remove barriers to access cataract surgery services must be established. Refractive correction alone reduced the prevalence of VI and blindness by 15.19%. Lack of eye care professionals who routinely examine visual and ocular status of nursing home residents is the major barrier faced by residents in Nepal to receive essential eye care services, such as refractive error correction. From our experience, there is lack of awareness regarding the treatment of visual disorders among nursing home residents. Residents believed that aged people do not benefit from glasses to improve vision and they could not get adapted to glasses. Affordability of glasses could also be another barrier to refractive error correction. We judged that VI and blindness can be avoided significantly by adequate refractive correction and cataract surgery among older people living in nursing homes. The strengths of this study include our measure that includes the NHVQoL questionnaire, which addresses all domains of vision-specific QoL. NHVQoL is specifically designed for nursing home residents and its subscales have demonstrated good internal consistency, reliability and validity.2,3,14,19,20 The questionnaire provides a valid interpretation of QoL based on the real-world visual needs of nursing Current Eye Research
Impact of Visual Impairment on Quality of Life
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TABLE 4 Comparison of mean subscales score of NHVQoL questionnaire from other studies. S.N. 1 2 3 4 5 6 7 8 9
Subscales
Present study (2011)
Lamoureux et al. (2009)2
Swanson et al. (2009)9; In highly VI group
Elliott et al. (2009)3; In VI group
General vision Reading Ocular symptom ADLs Mobility Social activities Psych. distress Adaptation Social int.
43.39 22.11 62.39 24.27 41.38 11.74 64.85 18.18 63.00 19.08 64.10 22.46 37.28 23.41 40.36 22.57 58.83 17.22
77.49 20.13 75.78 32.19 90.22 13.02 94.78 12.57 90.55 12.97 75.04 22.93 85.78 21.91 Included in 7 91.63 16.62
58.4 26.6 63.7 37.6 83.9 26.4 72.3 33.7 76.0 26.9 67.0 34.7 66.4 32.2 66.7 35.0 71.7 31.1
58.5 71.6 75.2 93.8 86.2 83.5 66.4 85.5 89.1
NHVQoL: Nursing Home Vision-Targeted Health-Related Quality of Life. VI: visual impairment. ADLs: activities of daily-livings. Psych: psychological. Int: interaction. Present and Elliott et al. studies: VI if VA56/18. Lamoureux et al. and Swanson et al. studies: VI if VA56/12.
home residents. The other strengths of this study is that to the best of our knowledge, there have been very few studies exploring the impact of VI on visionrelated QoL outside Nepal but no any such study has been done in Nepal till date. This can be very helpful in developing appropriate tool in the context to Nepalese nursing homes. Furthermore, this can guide in policy making for targeting interventions for Nepalese nursing home residents by the government and the concerned people. The study showed that there was a significant negative impact of VI on vision-specific QoL among nursing home residents. Vision-specific QoL was poor among all residents. QoL was associated with the severity of presenting distance VI. The higher the severity of presenting distance VI, the lower the corresponding mean and each subscale score of the NHVQoL instrument. This was consistent with the studies conducted by Lamoureux et al., Elliott et al. and Swanson et al.2,3,9 The mean score for each subscale of the NHVQoL questionnaire was much lower than the studies conducted by Lamoureux et al., Elliott et al. and Swanson et al.2,3,9 (Table 4). Potential explanations may be the low-level care status among Nepalese nursing homes (old age homes) compared to those in developed countries or may be due to fact that eye care interventions and rehabilitation programs are not prioritized by the Nepalese government or the concerned group. This study reflects typical relationships between distance and near VI and vision-specific QoL. The areas of QoL most affected were tasks pertinent to general vision, reading, activities of daily living, mobility, social activities and hobbies, psychological distress, adaptation and coping and social interaction. Not only moderate VI, even mild VI predicts a poorer QoL in activities associated with general vision, psychosocial distress and adaptation. The strength of the effect of VI on perceptions of QoL is so vital that the QoL is determined primarily by this visual disability even in the presence of other comorbid diseases.3 This study explores the !
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prevalence of VI and blindness and its impact on several vision-specific aspects of QoL. The information helps in understanding the impact of VI, psychosocial support and eye care interventions on QoL and in establishing prevention and rehabilitation programs for visually impaired persons living in nursing homes.3,22,23
CONCLUSION The prevalence of VI and blindness is high among older people living in nursing homes. Inadequate eye care services as well as poor uptake on available services are the problems in the nursing homes. There should be routine comprehensive eye care examination. Both the American Academy of Ophthalmology and the American Optometric Association recommend that all older adults have annual or biannual eye exams, which equally applies to nursing home residents.3,24,25 The study concludes that VI has a significant negative impact on vision-specific QoL. Vision-specific QoL is reduced and the reduction in the QoL bears a positive association with severity of VI among older people living in nursing homes. This study implies that vision-specific QoL among Nepalese nursing home residents is much lower than the nursing home residents of other countries in the world. Vision impairment and eye disease is higher in nursing home residents of Nepal than that of the other developed countries. This study suggests that in Nepal, psycho-social and eye care interventions and rehabilitation programs should be targeted toward older adults living in nursing homes.
RECOMMENDATION Multidisciplinary interventions programs involving adequate refractive error, timely utilization of cataract surgery and low vision rehabilitation to aid visually impaired residents and psycho-social components should be implemented to improve QoL of nursing
238 M. K. Dev et al. home residents.2,3,5,6 One outcome of this may be a reduction in the level of care they require from nursing staff.22,23 Future research should be directed at measuring the QoL among nursing home residents after they have received adequate refractive correction and cataract surgery and comparing the difference before and after the intervention.
10.
11.
ACKNOWLEDGEMENTS 12.
We would like to greatly appreciate and thank Joseph Clark, Sarita Pandey, Ravindra Adhikary, Sonisha Neupane, Mezbah Uddin, Raju Kaiti, Sarita Manandhar and Amrit Pokharel for their support and assistance.
13.
14.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This research was supported by Social Inclusion Research Fund (SIRF), Secretariat SNV, Bakhundole, Lalitpur, Nepal, as Matthias Moyersoen research apprenticeship grant.
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ORIGINAL ARTICLE
Impact of Visual Impairment on Vision-Specific Quality of Life among Older Adults Living in Nursing Home Mahesh Kumar Dev1, Nabin Paudel1,3, Niraj Dev Joshi1, Dev Narayan Shah1 and Shishir Subba2 1
Department of Ophthalmology, B. P. Koirala Lions Center for Ophthalmic Studies, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal, 2Central Department of Psychology, Tribhuvan University, Kathmandu, Nepal, and 3Department of Optometry and Vision science, The University of Auckland, Auckland, New Zealand
ABSTRACT
Keywords: : Blindness, kathmandu, nursing home, prevalence, quality of life, visual impairment
INTRODUCTION
20 14
Background: Visual impairment (VI) has a significant negative impact on quality of life (QoL) amongst older people living in nursing homes. The purpose of this study was to determine the prevalence of VI and blindness and to explore the association between severity of VI and vision-specific QoL among older people living in nursing homes of Kathmandu, Nepal. Methods: This cross-sectional study involved 158 residents aged 60 years or older residing in seven nursing homes of Kathmandu Valley, Nepal. Near acuity, presenting and the best corrected distance visual acuity (VA) were assessed in each eye and considered in the better eye after adequate refraction. A complete anterior and posterior segment examination was carried out. Face-to-face interviews were conducted using a 57-item Nursing Home Vision-Targeted Health-Related Quality of Life (NHVQoL) questionnaire. Results: The mean age of residents was 75.60 7.12 years and the majority were female (66.46%). The prevalence of VI and blindness was 45.57% and its leading cause was cataract, which was followed by age-related macular degeneration, corneal opacity, glaucoma and macular scar. The mean composite score of NHVQoL questionnaire was 52.22 12.49. There was a consistent overall deterioration in the mean composite score as well as each subscale score of NHVQoL questionnaire with a worsening of VA. Conclusion: VI and blindness are highly prevalent among older people living in nursing homes. VI has a significant negative impact on vision-specific QoL. Vision-specific QoL is reduced, and the reduction in the QoL bears a positive association with severity of VI among older people living in nursing homes.
Major causes of irreversible blindness such as retinal diseases, glaucoma, age-related macular degeneration (ARMD) as well as reversible causes like cataract are common in nursing homes. It is vital that vision care not be ignored in this population.1,12,13 VI has significant and deleterious impact on quality of life (QoL) and reduces vision-related QoL.2,3,5,6,14 Vision-related QoL is the present visual status and the
The prevalence of visual impairment (VI) and blindness is higher among older people living in nursing homes than that of the same base population living outside nursing homes because the former often do not have the same access to health care as do people living at home.1–12
Received 5 September 2012; revised 18 July 2013; accepted 23 August 2013; published online 21 October 2013 Correspondence: Mahesh Kumar Dev, B. Optom, B. P. Koirala Lions Center for Ophthalmic Studies, Department of Ophthalmology, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal. Tel: 977-9841633280. Fax: 977-1-4720142. E-mail: maheshdev2002@ gmail.com; [email protected]; [email protected]
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Impact of Visual Impairment on Quality of Life limitations in daily living activities like personal hygiene, communication, self-care, social skills, mobility, safety etc. as perceived by the subjects. Visual function is important for an optimal orientation in functional and social life and has effects on physical, psychological, mental and emotional well-being.1,14–18 Impaired vision significantly reduces activities associated with participation in society and religion, mobility, recreation and daily living etc.1–3,15,16 Vision loss in later life contributes to physical activity limitations, reduction in independent mobility, imbalance, risk of hip fractures, mortality and the need for community and/or family support.2,3,7,16,18 VI and blindness are major forms of disability in individuals living in nursing homes and these affect vision-specific functioning and socio-emotional aspects of daily living.1,2–4,16–20 Nursing home residents may be more prone to depression and other types of mental health problems due to impaired vision.2 Psychosocial adaptation status is significantly associated with vision-specific QoL, including the domains of mental health symptoms due to impaired vision. There is a little information about the impact of VI on vision-specific QoL as the majority of researches have been limited to the prevalence of VI and blindness but little attention has been paid to visionrelated QoL.3 The purpose of this study was to determine the prevalence of VI and blindness and to explore the relationship between severity of VI and vision-specific QoL. To the best of our knowledge, to date, no such study on impact of VI on vision-specific QoL among older people living in nursing homes has been done in Nepal.
MATERIALS AND METHODS Participants This was a descriptive, cross-sectional and institutionalized study conducted among older people living in seven different nursing homes of Kathmandu Valley, Nepal. The participants included in this study are among our earlier study population, which was primarily aimed at determining the prevalence of VI and blindness in nursing home residents.1 There were a total of 364 residents aged 60 years or older who performed complete ophthalmological examination, which included distance and near visual acuity (VA) assessment, refraction and a complete external and internal ocular examination; however, the interviews required for this study were completed only by 158 of those participants. There were various reasons for our inability to include all participants from our earlier study: some of them had disabilities and diseases like intellectual disabilities (6), Down’s syndrome (2), Alzheimer’s disease (2), hearing impairment (8), !
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inability to speak and listen (25) and bed ridden due to stroke (14) which affected their ability to provide proper responses, but a large number of residents (149) were excluded as they were not interested and hence did not give consent to this study. The information on various diseases and disorders of the residents was based on their medical records. For the enrollees of this study, informed consents were obtained both from the administrator of the nursing homes and from the residents themselves. Participants were eligible to participate if they agreed and were capable of answering questions about their vision and daily living activities. The results in this study are based on the 158 residents only who met our eligibility criteria. The institutional review board at the Institute of Medicine, Tribhuvan University, approved the study protocol, and the study followed the tenets of the Declaration of Helsinki. Enrollees’ particulars including age, sex, marital status, educational status and ethnicity were noted. Ethnicity classification was applied as per the Central Bureau of Statistics of Nepal.
Assessment Presenting distance VA was assessed with the Snellen chart at 6-metre distance in non-standardized outdoor illumination and near acuity with the Lighthouse Near Visual Acuity Card. Refraction was performed by an optometrist, and the best corrected distance VA was considered in the better eye. A complete anterior and posterior segment examination was carried out in all the residents by a team of optometrists and ophthalmologists. Anterior segment evaluation was carried out with a torch light and a handheld portable slit lamp. Posterior segment evaluation was done with a direct ophthalmoscope as well as a head-mounted binocular indirect ophthalmoscope. Intraocular pressure was measured with a handheld Perkins applanation tonometer.
Quality of Life Vision-related QoL was assessed by conducting faceto-face interview using a 57-item Nursing Home Vision-Targeted Health-Related Quality of Life (NHVQoL) questionnaire.14 The NHVQoL questionnaire, designed specifically for nursing home residents, was used to assess vision-targeted healthrelated QoL.2,3,14,19,20 The item design and question structure is based on the National Eye Institute-Vision Function Questionnaire. The questionnaire was designed to evaluate the impact of VI and eye disease on QoL and mental health in older nursing home residents and to assess the effectiveness of psychosocial and eye care interventions in nursing homes.
234 M. K. Dev et al. This instrument consists of nine subscales: general vision (6 items), reading (3 items), ocular symptoms (9 items), mobility (7 items), psychological distress (10 items), activities of daily living (6 items), social activities and hobbies (8 items), adaptation and coping (2 items) and social interaction (6 items). The NHVQoL was translated to Nepali and back translated to English to check the consistency in meaning. Few modifications were made in questions to make it suitable for Nepalese culture. Face validity was done with bilingual subjects to ensure that both versions provided the same response with the same score. Cronbach’s alpha of the sample of nine subscales score of NHVQoL was 0.801, which states good internal consistency and reliability of test scores. The face-to-face interviews were conducted by the primary author himself who was working with a psychologist and received training on research methodology and questionnaire administration. Few other assistants were trained by the author to help him in administering questionnaire. The agreement in the score values was compared between the interviewers randomly. There was a high agreement between the scores obtained from different interviewers. The NHVQoL questionnaire was scored according to the scoring algorithm NHVQoL subscales on a scale ranging from 0 to 100, with 0 indicating the lowest level of function (representing severe disability) and 100 indicating the highest level of function (representing
no disability).2,3,14,19,20 A high score indicates high QoL and a low score indicates poor QoL.
Statistical Analysis Recorded data were analyzed using Statistical Package for Social Sciences version 17.0 (SPSS, Chicago, IL, USA) and Microsoft Excel version 2010 (Redmond, WA, USA).
RESULTS Demographics of Study Participants Table 1 presents demographic characteristics. Mean age of the residents was 75.60 7.12 years (range, 60– 102 years). The majority of residents (43.67%, 69) were in the age range of 70–79 years. There was no statistically significant difference between the mean age of male (76.00 7.64 years) and female residents (75.40 6.88 years) (t-test, p = 0.66). The vast majority (66.46%, 105) were female residents and most were widowed (57%). Most of the enrollees (46.20%, 73) were advantaged Janajatis and the least (1.27%, 2) were of the Dalit category by ethnicity.
Near Acuity Mean presenting near acuity was 14 N (SD 2.21), and the best near acuity after appropriate near correction
TABLE 1 Demographics of the study enrollees (based on the best corrected distance VA). Severity of visual impairment, N (%) Characteristics Age range (years) 60–69 70–79 80–89 90–99 4100 Sex Male Female Race/ethnicity Upper caste Advantaged Janjatis Non-Dalit Terai Disadvantaged Janjatis Dalit Education Illiterate Simple read and write Primary school Secondary school
No. in each group N (%) 158 (100) 31 69 56 1 1
(19.62) (43.67) (35.45) (0.63) (0.63)
53 (33.54) 105 (66.46)
No VI 86 (54.43)
Moderate VI 46 (29.11)
Severe VI or worse 26 (16.46)
13 (41.94) 15 (21.74) 17 (30.36) – 1 (100.00)
3 (9.68) 9 (13.04) 14 (25.00) – –
27 (50.94) 59 (56.19)
16 (30.19) 30 (28.57)
10 (18.87) 16 (15.24)
15 45 25 1
(48.39) (65.22) (44.64) (100.00) –
54 73 3 26 2
(34.18) (46.20) (1.90) (16.46) (1.27)
29 46 2 9
(53.70) (63.01) (66.67) (34.62) –
19 16 1 9 1
(35.19) (21.92) (33.33) (34.62) (50.00)
6 (11.11) 11 (15.07) – 8 (30.77) 1 (50.00)
127 27 3 1
(80.38) (17.09) (1.90) (0.63)
63 20 2 1
(49.61) (74.07) (66.67) (100.00)
39 (30.71) 6 (22.22) 1 (33.33) –
25 (19.69) 1 (3.71) – –
VI: visual impairment. The percentage values in parentheses in the section ‘‘No. in each group’’ is out of the total 158 residents; however, the percentage values in parentheses for ‘‘severity of visual impairment’’ is by considering numbers in each subgroup as 100%. For instance, in the sex category, there were 53 males which is 33.54% of 158 residents and among them 27, which is 50.94% of 53 males, were normal or without VI. Current Eye Research
Impact of Visual Impairment on Quality of Life was 8 N (SD 1.53). The difference was statistically significant (Wilcoxon Signed Ranks Test, p50.05).
VI and Blindness Quantification of presenting and the best corrected distance VA was expressed in Snellen notation and was followed as that established by the World Health Organization and used in the International Classification of Diseases.21 According to this, VA was classified as: normal with no VI (VA 6/18), moderate VI (VA56/18–6/60), severe VI (VA56/60– 3/60), legally blind (VA53/60 – perception of light) and totally blind (no perception of light).21 As there were very few residents in legally blindness and totally blindness groups, these groups were merged with severely VI group and jointly considered as severely VI or worse group. Considering the presenting VA in the better eye, the prevalence of VI and blindness was 60.76%; but after appropriate refractive correction, the prevalence was reduced to 45.57% (Table 2). Refractive correction alone reduced the prevalence of VI and blindness by 15.19%, which was statistically significant (McNemar Test, p50.05). Cataract was the leading cause of non-refractive VI and blindness (47.22%) (Aphakia and pseudophakia were also included in cataract). Cataract was followed by ARMD (9.82%), corneal opacity (8.33%), glaucoma
TABLE 2 Presenting and best corrected distance VA in the better eye. Acuity (Snellen notation)
Presenting After correction N (%) N (%)
6/18 (normal/near normal) 62 56/18–6/60 (moderate VI) 65 56/60–NPL (severe VI or worse) 31 Total 158
(39.24) (41.14) (19.62) (100)
86 46 26 158
(54.43) (29.11) (16.46) (100)
VA: visual acuity. VI: visual impairment. NPL: no perception of light.
(7.0%), macular scar (6.73%), retinal degeneration and dystrophy (5.41 %) and others. There was no statistically significant difference between the prevalence of VI and blindness among upper caste (46.30%), advantaged Janajatis (36.99%), non-dalit Terai (33.33%) and the disadvantaged Janajatis (65.39%) (analysis of variance; ANOVA, p = 0.679).
Vision-Specific QoL The mean overall (composite) score of NHVQoL questionnaire was 52.22 12.49. Vision-specific QoL was reduced among nursing home residents. The reduction in vision-specific QoL score showed a negative correlation with the severity of presenting distance VI (Pearson’s R = –0.579) and was statistically significant (p50.05) (Figure 1). Table 3 presents mean score and each subscale score of NHVQoL instrument. The mean composite score of NHVQoL questionnaire decreased as the severity of presenting distance VI increased (worsening of VA). There was a gradual deterioration of scores from normal residents (i.e. having no VI) to moderate VI, severe VI or worse and accordingly QoL decreased gradually with increase in the severity of presenting distance VI. This was statistically significant between normal residents with no VI and residents with moderate VI (ANOVA, p50.05, 95% CI of the difference 5.34–13.61), between normal and severe VI or worse groups (ANOVA, p50.05,95% CI of the difference 4.91–19.22) and also between moderate VI and severe VI or worse groups (ANOVA, p50.05,95 % CI of the difference 3.76–14.94).
Association between Severity of VI and Subscales Score of NHVQoL Table 3 presents the relationship between presenting distance vision impairment and vision-specific QoL.
FIGURE 1 Relationship between severity of presenting distance VI and mean score of NHVQoL questionnaire. !
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236 M. K. Dev et al. TABLE 3 Mean score and each subscales score of NHVQoL questionnaire (based on presenting VA). NHVQoL indicators
Mean score
Composite score Mean (SD) General vision Reading Ocular symptom Activities of daily livings Mobility Social activities/hobbies Psychological distress Adaptation/coping Social interaction
52.22 43.39 62.39 41.38 64.85 63.00 64.10 37.28 40.36 58.83
(12.49) (22.11) (24.27) (11.74) (18.18) (19.08) (22.46) (23.41) (22.57) (17.22)
Normal 58.05 48.75 71.28 44.10 71.46 72.00 76.53 36.96 64.43 41.00
Moderate VI
(9.14) (22.51) (21.29) (12.62) (15.57) (14.13) (15.19) (24.72) (25.41) (15.67)
48.57 35.86 56.30 38.66 62.03 57.83 54.42 38.36 56.36 42.00
(9.43)* (15.52)* (21.73)* (9.99)* (15.93)* (18.52)* (15.03)* (20.88) (18.50) (12.39)*
Severe VI or worse 41.03 29.50 46.00 40.00 50.00 45.50 42.00 34.50 47.50 37.50
(11.89)* (20.56)* (23.98)* (8.54) (16.43)* (12.51) (24.96)* (23.16) (19.29) (18.87)
F value 21.12 6.77 10.38 3.08 12.68 21.19 30.83 1.20 1.34 10.21
NHVQoL: Nursing Home Vision-Targeted Health-Related Quality of Life. VI: visual impairment. *Indicates significant differences considering the normal group as a reference group.
There was a consistent overall deterioration in each subscale score of NHVQoL questionnaire with a worsening of distance vision except for ocular symptoms, psychosocial distress and adaptation subscales. There was a statistically significant difference in the mean score among normal, moderate VI and severe VI or worse groups in all subscales (ANOVA, p50.05) but not ocular symptoms, psychosocial distress and adaptation subscales.
DISCUSSION This study was conducted to determine the prevalence of VI and blindness and explore its impact on vision-specific QoL. The prevalence of VI and blindness (60.76%) at the presenting VA and even after refractive correction (45.57%) was significantly higher in comparison to the published data.10,12,13 This may be due to a lack of availability of services, but could be due to poor utilization of accessible eye care services by nursing home residents compared to people living at their own homes. It may be also because residents commonly do not wear spectacles even though they have them and they believe that aged people do not personally benefit from treatment intended to improve vision. We accept that our results might have been biased somehow toward higher prevalence of VI and blindness because the residents with whom interviews could not be conducted had slightly better VA (statistically non-significant) than the residents with whom interviews were conducted. The prevalence of VI and blindness was almost similar to that of the study by Owsley et al.4 Cataract was the leading cause of non-refractive VI and blindness (47.22%) followed by ARMD (9.82%), corneal opacity (8.33%), glaucoma (7.0%) and macular scar (6.73%). This was consistent with published data.1,4,12,13 The reasons for cataract to be the leading cause may be inadequate eye care services, high prevalence of mature cataract and inappropriately low use of cataract surgery. The major reason for the low use of cataract surgery among nursing home
residents of Nepal is due to lack of eye care professionals who routinely serve nursing home residents. Ocular health is still not included in the national health policy of the country. Neither the government nor any concerned group has paid any interest toward the routine and comprehensive eye examination of nursing home residents. The study conducted by Friedman et al.17 highlights that multiple obstacles prevent nursing home residents from undergoing cataract surgery. An important barrier was the lack of willingness of family members, guardians and the residents themselves to consent to surgery. Besides these, cultural beliefs regarding surgical interventions, lack of routine eye care services and transportation are some of barriers to access cataract surgery.17 Hence, it is essential to create awareness that cataract surgery is life enhancing and it improves the QoL. The programs to remove barriers to access cataract surgery services must be established. Refractive correction alone reduced the prevalence of VI and blindness by 15.19%. Lack of eye care professionals who routinely examine visual and ocular status of nursing home residents is the major barrier faced by residents in Nepal to receive essential eye care services, such as refractive error correction. From our experience, there is lack of awareness regarding the treatment of visual disorders among nursing home residents. Residents believed that aged people do not benefit from glasses to improve vision and they could not get adapted to glasses. Affordability of glasses could also be another barrier to refractive error correction. We judged that VI and blindness can be avoided significantly by adequate refractive correction and cataract surgery among older people living in nursing homes. The strengths of this study include our measure that includes the NHVQoL questionnaire, which addresses all domains of vision-specific QoL. NHVQoL is specifically designed for nursing home residents and its subscales have demonstrated good internal consistency, reliability and validity.2,3,14,19,20 The questionnaire provides a valid interpretation of QoL based on the real-world visual needs of nursing Current Eye Research
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TABLE 4 Comparison of mean subscales score of NHVQoL questionnaire from other studies. S.N. 1 2 3 4 5 6 7 8 9
Subscales
Present study (2011)
Lamoureux et al. (2009)2
Swanson et al. (2009)9; In highly VI group
Elliott et al. (2009)3; In VI group
General vision Reading Ocular symptom ADLs Mobility Social activities Psych. distress Adaptation Social int.
43.39 22.11 62.39 24.27 41.38 11.74 64.85 18.18 63.00 19.08 64.10 22.46 37.28 23.41 40.36 22.57 58.83 17.22
77.49 20.13 75.78 32.19 90.22 13.02 94.78 12.57 90.55 12.97 75.04 22.93 85.78 21.91 Included in 7 91.63 16.62
58.4 26.6 63.7 37.6 83.9 26.4 72.3 33.7 76.0 26.9 67.0 34.7 66.4 32.2 66.7 35.0 71.7 31.1
58.5 71.6 75.2 93.8 86.2 83.5 66.4 85.5 89.1
NHVQoL: Nursing Home Vision-Targeted Health-Related Quality of Life. VI: visual impairment. ADLs: activities of daily-livings. Psych: psychological. Int: interaction. Present and Elliott et al. studies: VI if VA56/18. Lamoureux et al. and Swanson et al. studies: VI if VA56/12.
home residents. The other strengths of this study is that to the best of our knowledge, there have been very few studies exploring the impact of VI on visionrelated QoL outside Nepal but no any such study has been done in Nepal till date. This can be very helpful in developing appropriate tool in the context to Nepalese nursing homes. Furthermore, this can guide in policy making for targeting interventions for Nepalese nursing home residents by the government and the concerned people. The study showed that there was a significant negative impact of VI on vision-specific QoL among nursing home residents. Vision-specific QoL was poor among all residents. QoL was associated with the severity of presenting distance VI. The higher the severity of presenting distance VI, the lower the corresponding mean and each subscale score of the NHVQoL instrument. This was consistent with the studies conducted by Lamoureux et al., Elliott et al. and Swanson et al.2,3,9 The mean score for each subscale of the NHVQoL questionnaire was much lower than the studies conducted by Lamoureux et al., Elliott et al. and Swanson et al.2,3,9 (Table 4). Potential explanations may be the low-level care status among Nepalese nursing homes (old age homes) compared to those in developed countries or may be due to fact that eye care interventions and rehabilitation programs are not prioritized by the Nepalese government or the concerned group. This study reflects typical relationships between distance and near VI and vision-specific QoL. The areas of QoL most affected were tasks pertinent to general vision, reading, activities of daily living, mobility, social activities and hobbies, psychological distress, adaptation and coping and social interaction. Not only moderate VI, even mild VI predicts a poorer QoL in activities associated with general vision, psychosocial distress and adaptation. The strength of the effect of VI on perceptions of QoL is so vital that the QoL is determined primarily by this visual disability even in the presence of other comorbid diseases.3 This study explores the !
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prevalence of VI and blindness and its impact on several vision-specific aspects of QoL. The information helps in understanding the impact of VI, psychosocial support and eye care interventions on QoL and in establishing prevention and rehabilitation programs for visually impaired persons living in nursing homes.3,22,23
CONCLUSION The prevalence of VI and blindness is high among older people living in nursing homes. Inadequate eye care services as well as poor uptake on available services are the problems in the nursing homes. There should be routine comprehensive eye care examination. Both the American Academy of Ophthalmology and the American Optometric Association recommend that all older adults have annual or biannual eye exams, which equally applies to nursing home residents.3,24,25 The study concludes that VI has a significant negative impact on vision-specific QoL. Vision-specific QoL is reduced and the reduction in the QoL bears a positive association with severity of VI among older people living in nursing homes. This study implies that vision-specific QoL among Nepalese nursing home residents is much lower than the nursing home residents of other countries in the world. Vision impairment and eye disease is higher in nursing home residents of Nepal than that of the other developed countries. This study suggests that in Nepal, psycho-social and eye care interventions and rehabilitation programs should be targeted toward older adults living in nursing homes.
RECOMMENDATION Multidisciplinary interventions programs involving adequate refractive error, timely utilization of cataract surgery and low vision rehabilitation to aid visually impaired residents and psycho-social components should be implemented to improve QoL of nursing
238 M. K. Dev et al. home residents.2,3,5,6 One outcome of this may be a reduction in the level of care they require from nursing staff.22,23 Future research should be directed at measuring the QoL among nursing home residents after they have received adequate refractive correction and cataract surgery and comparing the difference before and after the intervention.
10.
11.
ACKNOWLEDGEMENTS 12.
We would like to greatly appreciate and thank Joseph Clark, Sarita Pandey, Ravindra Adhikary, Sonisha Neupane, Mezbah Uddin, Raju Kaiti, Sarita Manandhar and Amrit Pokharel for their support and assistance.
13.
14.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This research was supported by Social Inclusion Research Fund (SIRF), Secretariat SNV, Bakhundole, Lalitpur, Nepal, as Matthias Moyersoen research apprenticeship grant.
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