The Relationship between Low Vision and Performance of lActivities of Daily Living in Nursing Home Residents Marcia S. Marx, PhD,* Perla Werner, MA,t Jiska Cohen-Mansfield, PhD,*t and Roberf Feldman, MD* Objective: To explore the link between low vision and Activities of Daily Living (ADL) performance in cognitively intact nursing home residents. Design: Survey. Setting: A non-profit geriatric long-term care facility. Subjects: 21 males, 82 females, aged 66-98. Measures: Survey of 103 nursing home residents. ADL functioning assessed via Maryland Appraisal of Patient Progress (MAPP); medical data collected through chart review; ophthalmological data obtained through dilated eye examination by an ophthalmologist. Results: In comparison with residents having good vision (n = 52), a significantly greater proportion of residents with

low vision (n = 51) were dependent on caregivers for performing ADLs (eg, toileting, transferring, washing). Residents with low vision had significantly more eye pathology (eg, cataracts, age-related macular degeneration) than did residents with good vision. There were no significant differences between groups with regard to presence of musculoskeletal problems (eg, arthritis) or number of medical conditions (eg, cardiovascular disorder, cerebrovascular accident). Conclusions: There is a strong link between low vision and ADL disability in nursing home residents. Moreover, ADL dependency is significantly related to the presence of eye disorders. J Am Geriatr SOC 401018-1020,1992

any of the elderly persons who live in nursing homes suffer from some type of eye pathology; the most common are cataracts, glaucoma, and age-related macular degeneration. According to recent reports from two nursing homes, cataracts were found in over 80% of the nursing home residents in each facility.'** The percentage of nursing home residents in these two studies with glaucoma ranged from 4% to 11%.',' Age-related macular degeneration was found in 29% of the residents in one study' and in 37% of the residents in the other study.' Left untreated, cataracts, glaucoma, and age-related macular degeneration can lead to profound loss of vision. Despite the fact that the presence of such vision loss could have deleterious effects on a nursing home resident's ability to perform the most basic activities of daily living (ADLs) (ie, eating, dressing, walking), only Horowitz has examined this issue.' Horowitz found that overall dependency in ADL performance correlated significantly with low vision (ie, visual acuity of 20/70 or worse in the best corrected eye) in a group of 114 nursing home residents.' In the present paper, we further examine the relationship of low vision with ability to perform ADLs, considering the influence of other conditions that have been reported in the literature as negatively affecting ADL performance in nursing home residents (eg, arthritis, stroke). Since it is well known that a strong relationship exists between ADL impairment and cognitive d e ~ l i n e we , ~ present data only from cognitively

intact nursing home residents. We extend the findings of Horowitz' by demonstrating that not only are nursing home residents with low vision more ADL dependent but nursing home residents with low vision are the same persons who have more eye pathology, such as age-related maculopathy and cataracts.

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From the *Research Ins!itnte of the Hebrew Home of Greater Washington, Rcckville, Maryland, and S e n t e r on Aging, Georgetown University School of Medicine, Washington, DC. Portions of this paper were presented at the 1990 annual meeting of the Association for Research m Vision and Ophthalmology in Sarasota, Florida. Address correspondence to Perla Werner, MA, Research Institute, Hebrew Home of Greater Washington, 6121 Montrose Rd., Rockville, MD 20852.

JAGS 40:1018-1020, 1992 0 1992 by :he American Gniutrics Society

METHODS Study Participants Data were obtained from 103 nursing home residents (mean age = 85.4 years) who were examined by an ophthalmologist in the eye clinic of the nursing home. All participants were oriented to time, place, and person (assessed via the Maryland Appraisal of Patient Progress, MAPP).' Of these, 52 residents had good vision (defined as best corrected Snellen distance visual acuity of 20/40 or better in the better eye), and 51 residents had low vision (defined according to the US National Center for Health Statistics in the International Classification of Diseases5 as best corrected Snellen distance acuity of 20/70 or worse in the better eye). The participants' visual acuity was assessed using the Early Treatment Diabetic Retinopathy (ETDRS) chart. Characteristics of these residents are presented in Table 1. The mean age of residents with good vision was 84.8 years, and the mean age of residents with low vision was 86 years. In both groups, approximately 80% of the residents were female, and about 60% wore glasses for distance. Bivariate analyses failed to find significant differences between groups with respect to age, gender, and whether glasses were worn. For each resident, the degree of assistance needed to perform seven activities of daily living (ADL) was assessed by that resident's charge nurse using the MAPP.4 The ADL items (each rated as "1"-independent/needs some assistance or "2"-completely dependent) were toileting, transferring from bed to chair, 0002-8614/92/$3.50

IAGS-OCTOBER 1992-VOL.40, NO.10

ADL DEPENDENCY AND LOW VISION

bathing or showering, washing hands or face, dressing the upper body, dressing the lower body, and whether the resident was wheelchair-dependent. In addition, each resident received a dilated eye examination by an ophthalmologist, and, if indicated, a refraction was performed by the ophthalmologist (more detailed information regarding the eye examination is provided in reference 6). The presence of the following eye disorders was recorded: age-related macular degeneration, cataract, glaucoma, and diabetic retinopathy. Diabetic retinopathy was excluded from subsequent analyses since this disorder was found in only two study participants. Other data were obtained via chart review by a trained researcher. Whether or not the resident had a positive history of a hip fracture or suffered from arthritis or rheumatism was recorded. It was considered crucial to obtain these data since previous reports have shown thdt these conditions can adversely affect ADL performance independently of the contibution of poor ~ i s i o n In . ~ addition, the presence or absence of the following medical conditions was recorded: cardiovascular disorders, diabetes, hypertension, pulmonary disorders (eg, emphysema, chronic bronchitis), history of a cerebrovascular accident, and Parkinson's disease, since these have been linked with ADL dependency in nursing home resident^.^

RESULTS To examine the relationship between vision group and ADL dependency, 2 X 2 chi-square analysis was performed on the data pertaining to each ADL. For these analyses, the row variable was vision group (low vision vs good vision), and the column variable was dependency in ADL ("independent"/"needs some asTABLE 1. CHARACTERISTICS OF NURSING HOME RESIDENTS IN GOOD AND LOW VISION GROUPS Good Vision Low Vision (n = 52) (n = 51) Age Mean Range Gender (%) Male Female Wears glasses (%)

84.8 66-98

86.0 68-97

11 (21) 41 (79) 31 (61)

10 (20) 41 (80) 30 (59)

1019

sistance" vs "dependent") (see Table 2). Analyses revealed that 47% of the residents with low vision, in comparison with 19%of the residents with good vision, were dependent on caregivers for toileting (x2(*) = 9.07, P < 0.01). Twenty percent of the residents in the low vision group were totally dependent on others for transferring from bed to chair, while only 2% of the residents with good vision were dependent for this ADL (x'(~) = 8.44, P = 0.01). Results also revealed that residents in the low vision group were significantly more dependent on caregivers for washing themselves and dressing the upper parts of the body than were residents in the good vision group ( ~ ~ ( 1= ) 4.82, 5.07, respectively, P < 0.05). A similar trend was seen for dressing the lower parts of the body, bathing, and whether the resident was wheelchair-bound; however, these results did not reach statistical significance. Another analysis was undertaken to determine whether residents with low vision were dependent on caregivers for a greater number of ADLs than were residents with good vision. An ANOVA was performed with the independent variable being the vision group and the dependent variable the number of ADLs (out of a possible 7) for which the resident was dependent on caregivers. In each vision group, the number of ADLs for which residents were dependent ranged from 0 to 7. Results of the ANOVA showed that residents in the low vision group were dependent for an average of 2.9 ADLs, while residents in the good vision group were dependent for an average of 1.6 ADLs (F(l,l~l) = 8.83, P < 0.01). In order to rule out the possibility that variables other than vision group could account for the observed differences in ADL dependency between residents with low versus good vision, additional analyses were performed. First, since musculoskeletal problems often lead to severe disability and loss of independence in the elderly, three 2 X 2 chi-squares were performed in which vision group was evaluated relative to the presence of arthritis, rheumatism, and history of a hip fracture. No significant differences emerged between low and good vision groups for any analysis. Second, to rule out the possibility that residents in the low vision group suffered from a greater number of medical conditions which in turn could lead to greater ADL dependency, independently of the contibution of vision loss, we determined the number of medical diagnoses for each resident in the low and

TABLE 2. PERCENTAGE (AND NUMBER) OF NURSING HOME RESIDENTS IN EACH VISION GROUP WHO WERE DEPENDENT FOR EACH OF 7 ADLS AND THE CORRESPONDING CHI-SQUARE STATISTICSa % Good Vision % Low Vision (n = 52) (n = 51) XZ Toileting 19 (10) 47 (24) 9.02** 20 (10) 8.44** Transferring 2 (1) Washing face/hands 21 (11) 41 (21) 4.82* 29 (15) 5.07* Dressing upper body 11 (6) Dressing lower body 19 (10) 32 (16) 2.19 Bathing/showering 31 (16) 47 (24) 2.88 Wheelchair-dewndent 58 (30) 71 (36) 1.86 Each on 1 degree of freedom. ** P < 0.01; * P < 0.05. a

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good vision groups (based on the absence or presence of cardiovascular disorder, diabetes, hypertension, pulmonary disorder, Parkinson’s disease, and cerebrovascular accident). An ANOVA was performed on these data. The independent variable was the vision group; the dependent variable was the number of medical diagnoses. In each of the two vision groups, the number of medical diagnoses ranged from 0 to 3. Results of the ANOVA failed to reach statistical significance (the mean number of medical diagnoses was 1.1 for the good vision group and 1.6 for the low vision group). Findings from the final set of analyses showed that low vision is related to specific eye disorders (Table 3). Results of a 2 X 2 chi-square revealed that 59% of the low vision group, in comparison with 39% of the good vision group, had age-related macular degeneration in one or both eyes (x2(,) = 4.27, P < 0.05). In addition, cataracts were found in one or both eyes of 55% of the residents in the low vision group and in only 33% of the residents in the good vision group (x2(,) = 5.16, P < 0.05). Twenty-two percent of the residents in the low vision group and 10% of the residents in the good vision group had glaucoma, although the chi-square statistic was not significant.

DISCUSSION We found that nursing home residents with low vision are dependent for a significantlygreater number of ADLs than are residents with good vision. Moreover, our results suggest that ADL dependency in residents with low vision is related to the presence of cataracts and age-related macular degeneration. Thus, it appears that cataracts and age-related macular degeneration may contribute to excess disability, ie, the amount of the disability that exceeds the amount accounted for by the actual physical impairment. Future studies are needed to further examine and extend these findings by evaluating other measurements of visual function such as: depth perception, eye hand coordination, visual motor integration, peripheral vision, and contrast sensitivity. Cataracts are one of the major causes of reversible visual impairment in the elderly. Indeed, the improvement in vision following cataract extraction with intraocular lens implant can be quite dramatic in a nursing home resident.6 In the case of residents who have lost vision due to age-related macular degeneration or glauTABLE 3. PERCENTAGE (AND NUMBER) OF NURSING HOME RESIDENTS IN EACH VISION GROUP WITH AGE-RELATED MACULAR DEGENERATION, CATARACT, AND GLAUCOMA AS WELL AS THE CORRESPONDING CHI-SQUARES % Good Vision % Low Vision (n = 52) (n = 51) x2 Macular degeneration Cataract Glaucoma Ench on 1 degree ., of, ,freedom. * P < 0.05.

a

39 (20) 33 (17) 10 (5)

59 (30) 55 (28) 22 (11)

4.27*

5.16* 2.80

coma, vision cannot be regained through surgery. Regardless of the type of eye pathology, residents need to be given every opportunity to maximize their residual vision so that they can remain independent for as long as possible. One way to accomplish this is through the use of low vision aids and visual enhancement strategies such as high contrast labels (eg, bold line pens, striped hallways and steps, contrasting color toilet seats). These aids can and should be introduced into the nursing home. Future studies should compare the cost effectiveness of performing low vision examinations and providing instruction in low vision aids and independent living skills with the cost of providing routine nursing home care to frail elderly with impaired vision. At present, nursing home residents who might benefit from low vision aids do not usually receive them. In fact, the majority of nursing homes in the United States do not offer routine vision screening for their residents.* Thus, residents with low vision are rarely diagnosed as such. Clearly, nursing home administrators, as well as other persons in policy-making positions, need to push for the institution of vision services in nursing homes. In the nursing home where this study was conducted, a low vision clinic was recently started. This clinic serves nursing home residents, who are referred to the clinic by the ophthalmologist after an eye exam, as well as community elderly. In conclusion, our finding that low vision is linked with ADL dependency raises the possibility that residents with low vision may place a greater burden on nursing staff than do residents with good vision. Given the nationwide problem with overwork, stress, and turnover of nursing home staff, it is imperative that all possible measures be taken to relieve the burden placed on nursing home staff. One way to do this would be to provide routine screening for eye disorders, to treat reversible conditions whenever possible, and to institute low vision training in the nursing home.

REFERENCES 1. Horowitz A. The prevalence and consequences of visual impairment among nursing home residents. Monograph of the Lighthouse, Inc. New York, 1988. 2. Whitmore WG. Eye disease in a geriakic nursing home population. Ophthalmology 1989;96:393. 3. Zillmer E, Passuth P. Predicting functional ability from mental status among nursing home residents.(Abstract) Proceedings of the 42nd Annual Scientific Meeting of the Gerontological Society of America 1989;29: 142A. 4. Maryland Appraisal of Patient Progress (MAPP):A Patient Care Management System Instruction Manual. Baltimore, M D Maryland Department of Health and Mental Hygiene, Division of Licensing and Certification, 1982. 5. International Classification of Diseases, 9th Revision, Clinical Modification,ICD-9-CM, 2nd Ed. United States National Center for Health Statistics: Ann Arbor, MI, 1980. 6. Marx MS, Wolf D, Pheng L, et al. Eye care in a nursing home. J Visual Impairment & Blind 1991;85:105. 7. National Nursing Home Survey (NNHS): 1977 Summary for the United States. DHEW Publication No. (PHS) 79-1794. Washington, D C U.S. Government Printing Office, 1979. 8. Beliveau M, Yeadon A, Aston S. Innovative curriculum development research To develop in-service training curriculum for providers of longterm care to elderly blind/visually impaired. Final report to the National Institute for Handicapped Research, Innovation Grant No. G008535147, 1986.

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

To explore the link between low vision and Activities of Daily Living (ADL) performance in cognitively intact nursing home residents...
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