Tutorial
Introduction
Falls
Hearing Loss
Depression
Dementia
Overall Function
Driving Impairment
Low Vision
Elder Abuse
Summary
Bibliography

Functional Impact of Visual Loss in the Aged Patient

Andrew G. Lee, MD

Introduction

The aging population in the United States will cause a demographic shift in medical care. The aging boom is due in part to the increase in average life expectancy (75.5 years in 1991) and the aging of post-World War II baby boomers. By conservative projections, 20% of people will be older than 65 years of age in the year 2030 and 5.6 million people will be older than 85 years of age by the year 2010. The elderly population consumes a disproportionate one-third share of U.S. health care and that rate may reach 50% of the U.S. health care dollar by 2030. An increasing need for geriatric expertise in all the medical subspecialties, including ophthalmology, will occur. Ophthalmologists should be aware of the functional impact of visual loss in the aged patient. Visual impairment and blinding disorders occur with increasing frequency with age. Eye care providers, however, should also recognize that poor visual function affects other quality of life parameters including disability, falls and fractures, activities of daily living and independence, the use of community support services, sense of well being, and mortality.

Falls

Falls occur in a significant number (up to 35%) of older individuals each year. Numerous studies have established that poor vision is a risk factor (up to 3-fold higher) for falls. In the Beaver Dam Eye Study, 11% (943) of 2365 subjects (aged 60 years or older) with acuity less than 20/25 had a fall in the prior year compared to 4.4% of those with normal visual acuity. In an elderly patient with a history of falls or at risk for falling, ophthalmologists should consider interventions including:

• Increasing lighting and decreasing glare
• Increasing contrast at dangerous areas such as corners and on steps
• Removing floor obstacles, minimizing clutter, and reducing floor hazards (e.g., anchoring loose rugs and eliminating uneven surfaces)
• Using well-designed hand rails and furnishings (e.g., use of non-skid flooring)
• Using appropriate walking devices (stable walker and cane types)
• Avoiding improper footwear (e.g., high-heeled shoes)

Hearing Loss

Newer treatments for hearing loss are emerging that can improve the synergistic impact of hearing loss on the visually impaired. Ophthalmologists should recognize and refer these patients to an otolaryngologist.

Depression

Visual impairment can cause, worsen, or precipitate clinical depression in the elderly. Impaired vision and depression have been associated with functional impairment. Recognizing and treating depression may reduce excess disability associated with impaired vision. A single simple screening question might be sufficient for detecting patients at risk for concomitant depression (i.e., "Do you often feel sad or depressed?"). Elderly patients with depression may present with visual complaints as their initial manifestation of depression and, conversely, patients with significant visual loss are at higher risk for depression.

Dementia

Visual loss is associated with and may worsen dementia. Visual impairment was associated with an increased risk for and an increased clinical severity of Alzheimer's disease. Patients with dementia may have a homonymous hemianopsia or be cortically blind despite a negative structural imaging study (e.g., normal cranial magnetic resonance imaging). Visual complaints may be the presenting manifestation of dementia (e.g., difficulty reading, getting lost easily, seeing but not being able to read). Several screening tests have been proposed (e.g., mini-COG). Another simple rapid screening tool is the clock draw. A patient is asked to draw a clock face including the numbers 1 to 12 and fill in the time at "zero minutes past 11 o'clock." Patients who fail the clock draw should undergo appropriate evaluation and treatment for possible dementia.

Overall Function

Several population-based studies have shown an association between visual impairment and overall function. Patients with poor vision are more likely to have significant impairment in instrumental activities of daily living (e.g., grocery shopping, paying bills, cleaning house, answering the telephone, cooking meals). Visual loss decreases basic independence and mobility (e.g., walking, going outside, and getting in and out of bed).

Driving Impairment

Visual loss in the elderly impairs the ability to drive. Cataract and glaucoma are also a significant risk factor for automobile crashes in the elderly. Ophthalmologists should recognize that co-morbidities other than visual loss can result in impaired driving ability in the elderly. Appropriate driving assessment, driving self-restriction, or formal testing may be required. Although many elderly voluntarily stop driving after dark, most resist suggestions to cease driving completely. It is an ophthalmologist's responsibility to the patient and to society to prevent the seriously visually impaired patient from driving.

Low Vision

Low vision rehabilitation can improve visual function in patients who have maximized medical or surgical therapy. Recognition and referral of appropriate candidates for low vision assistance is an important role for the ophthalmologist.

Elder Abuse

In addition to the functional impact of visual loss, the ophthalmologist should recognize and refer patients suffering from possible abuse. Although there is widespread awareness in the ophthalmic community regarding child abuse, the signs of elder abuse are not as well known. Elder abuse may take the form of physical neglect (e.g., physical abuse, withholding of food or water, medical care, medication, or hygiene); psychological neglect (e.g., verbal abuse, loss of privacy); or financial neglect (e.g., denial of transportation, financial abuse, or exploitation). An ophthalmologist should be aware of the following red flags for elder abuse:

• Repeated visits to the emergency department or the clinic without organic cause
• Conflicting or non-credible history of eye injury or disease from caregiver or patient
• Unexplained delay in seeking treatment for eye condition
• Unexplained, inconsistent, vague, or poorly explained ocular injuries
• History of being inappropriately "accident-prone"
• Expressions of ambivalence, anger, hostility, or fear by the patient toward the caregiver
• Unexplained poor compliance with follow-up or care instructions
• Evidence for physical abuse (e.g., skin bruises, lacerations, wounds in various stages of healing, unusually shaped bruises, burns, welts, patches of hair loss, unexplained subconjunctival, retinal or vitreous hemorrhage).

The clinician may need to obtain the history without the caregiver's presence. Specific and directed questions regarding abuse include "Has anyone at home tried to harm you?" "Has anyone tried to make you do things that you do not wish to do?" and "Has anyone taken anything from you without your consent?"

Suspected cases of elder neglect or abuse require written and perhaps photographic documentation. Many states have mandatory reporting and ophthalmologists should be aware of local statutes, available services for adult protection, community social and support service, and law enforcement requirements.

Summary

Ophthalmologists should recognize the functional impact of visual impairment in the elderly. Recognition and treatment of co-morbidities (e.g., depression, dementia, hearing loss) might improve the functional outcomes of patients with visual impairment. Patients with visual loss are at higher risk for driving accidents and falls and appropriate interventions to prevent these events are more effective than treatment after the fact. Low vision services should be considered in all patients with visual impairment. Patients should never be told that there is "nothing that can be done" or that it is "just old age."

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