Ellen E. Freeman

Driving Status and Risk of Entry Into Long-Term Care in Older Adults

OBJECTIVES Given the importance of driving in American society, older non-drivers may be unable to meet basic needs while living independently. We assessed whether not driving is an independent risk factor for entering long-term care (LTC) institutions. METHODS Data were used from 1593 older adults who participated in the Salisbury Eye Evaluation cohort study and completed an additional telephone survey. Questions on driving status and LTC entry were obtained by self/proxy report. Cox time-dependent regression procedures were used to adjust for demographic and health factors. RESULTS Former and never drivers had higher hazards of LTC entry after adjustment for demographic and health variables (hazard ratio [HR]=4.85; 95% confidence interval [CI]=3.26, 7.21; and HR=3.53; 95% CI=1.89, 6.58, respectively). Also, having no other drivers in the house was an independent risk factor for LTC entry (HR=1.72; 95% CI=1.15, 2.57).Discussion. Older adults are expected to make good decisions about when to stop driving, but the hardships imposed on older adults by not driving are not widely recognized. Innovative strategies to improve transportation options for older adults should be considered.

Measures of Visual Function and Time to Driving Cessation in Older Adults

Purpose. Older adults may place restrictions on their driving once their visual function has become compromised, presumably in an effort to ensure their safety. It is important to identify the types of visual function loss that lead to driving cessation to better understand the relationship between vision and driving. Methods. Data were used from the Salisbury Eye Evaluation project, a cohort study of 2520 older adults followed for 8 years with four rounds of data collection. Multiple measures of visual function were objectively assessed and driving information was collected through self-report from subjects or proxies. Cox regression was used to examine whether those with worse baseline and 2-year change scores in acuity, contrast sensitivity, visual fields, and glare sensitivity were more likely to stop driving after baseline after adjusting for demographic and health variables. Results. Those with worse baseline scores in acuity, contrast sensitivity, central or lower peripheral visual fields were more likely to stop driving (trend p values < 0.05). Also, those who experienced 2-year losses in acuity, contrast sensitivity, or lower peripheral visual fields were more likely to stop driving (trend p values < 0.05). With the vision variables entered into the same model, baseline acuity and 2-year acuity loss were no longer statistically significant. Those with worse baseline scores in contrast sensitivity, central and lower peripheral visual fields were more likely to stop driving (trend p values < 0.05), and those who had 2-year losses in contrast sensitivity and lower peripheral visual fields were more likely to stop driving (trend p values < 0.05). Interactions with gender, other drivers in the house, or cognitive impairment were not detected. Conclusions. We present prospective data that indicate that older adults with worse scores in multiple measures of vision are more likely to stop driving and that contrast sensitivity and visual fields are most associated with driving cessation.

Explaining the Relationship between Three Eye Diseases and Depressive Symptoms in Older Adults

PURPOSE The purpose of this study is to examine whether patients with age-related eye diseases, like age-related macular degeneration (AMD), glaucoma, or Fuchs corneal dystrophy, are more likely to show signs of depression compared to a control group of older adults with good vision, and to determine whether reduced mobility mediates these relationships. METHODS We recruited 315 eligible patients (81 with AMD, 55 with Fuchs, 91 with glaucoma, and 88 controls) from the ophthalmology clinics of a Montreal hospital from September 2009 until December 2011. Depressive symptoms were assessed using the Geriatric Depression Scale Short Form (GDS-15). Life space was measured using the Life Space Assessment. Logistic regression was used to adjust for demographic, health, and social factors, and mediation was assessed using the methods of Baron and Kenny. RESULTS There were 78 people (25%) meeting the criteria for depression in the cohort. All three groups with eye disease were more likely to be depressed than the control group after adjusting for age, sex, ethnicity, education, cognitive score, limitations in activities of daily living, social support, and lens opacity (P < 0.05). Life space and limited activities due to a fear of falling appeared to mediate the relationship between eye disease and depression. CONCLUSIONS Visually limiting eye disease is associated with depression in older adults. Further research on interventions to prevent depression in patients with eye disease is warranted and should consider strategies to alleviate mobility limitation. Greater attention from families, physicians, and society to the mental health needs and mobility challenges of patients with eye disease is needed.

Rate of Endophthalmitis After Cataract Surgery in Quebec, Canada, 1996-2005

OBJECTIVE To estimate the annual incidence of endophthalmitis after cataract surgery from January 1, 1996, through December 31, 2005, in Quebec, Canada. METHODS Deidentified data were obtained from an outpatient physician billing database (Quebec State Control for Health Insurance [RAMQ]) with regard to all cataract surgical procedures performed from January 1, 1996, through December 31, 2005, in Quebec. For this cohort, records of an International Classification of Diseases, Ninth Revision (ICD-9) code for endophthalmitis during the same years were requested from 2 sources: the RAMQ outpatient database and an inpatient hospital discharge database (Maintenance and Exploitation of Data for the Study of Hospitalized Patients [MED-ECHO]). Endophthalmitis after cataract surgery was assumed if it occurred within 90 days of the surgery. Risk factors were examined using chi(2) tests and logistic regression. RESULTS After exclusions, 490 690 cataract surgical procedures were performed from January 1, 1996, through December 31, 2005. A total of 754 cases of endophthalmitis occurred within 90 days after surgery for an overall incidence rate of 1.5 per 1000 surgical procedures (95% confidence interval [CI], 1.4-1.7). Factors associated with endophthalmitis included age of 85 years or older (odds ratio [OR], 1.34; 95% CI, 1.06-1.70), male sex (1.44; 1.24-1.66), later year of surgery (0.94; 0.92-0.97), and region of cataract surgery, because regions 6 (2.21; 1.91-2.55) and 9 (4.00; 2.48-6.43) had higher rates compared with all other regions. CONCLUSION Reasons that explain the apparent decrease in endophthalmitis, especially in 2005, should be explored and further research performed to understand why certain patients and regions have higher risks of endophthalmitis after cataract surgery.

The Global Burden of Visual Difficulty in Low, Middle, and High Income Countries

Purpose Using a world-wide, population-based dataset of adults, we sought to determine the frequency of far visual difficulty and its associated risk factors. Methods The World Health Survey (WHS) was conducted in 70 countries throughout the world in 2003 using a random, multi-stage, stratified, cluster sampling design of adults ages 18 years and older. Far vision was assessed by asking “In the last 30 days, how much difficulty did you have in seeing and recognizing a person you know across the road (i.e. from a distance of about 20 meters)?”. Responses included none, mild, moderate, severe, or extreme/unable. The income status of countries was estimated using gross national income per capita data from 2003 from the World Bank. Prevalence and regression estimates were adjusted to account for the complex sample design. Results 21% of adults reported any visual difficulty. The rate varied by the income status of the country with the percentage who had any visual difficulty being 24%, 23%, and 13% in low, middle, and high income countries, respectively. Five percent of people reported severe or extreme visual difficulty with rates in low, middle, and high income countries of 6%, 5%, and 2% respectively. Risk factors for visual difficulty included older age, female sex, poorer socioeconomic status, little to no formal education, and diabetes (P<0.05). Conclusions One out of five adults in the WHS reported some degree of far visual difficulty. Given the importance of vision to living an independent life, better access to quality eye care services and life course factors affecting vision health (e.g. repeated eye infections, diet lacking vitamin A) must receive adequate attention and resources, especially in low and middle income countries.

Activity Limitation due to a Fear of Falling in Older Adults with Eye Disease

PURPOSE To examine whether patients with age-related macular degeneration (AMD), glaucoma, or Fuchs corneal dystrophy report limiting their activity due to a fear of falling as compared with a control group of older adults with good vision. METHODS We recruited 345 patients (93 with AMD, 57 with Fuchs, 98 with glaucoma, and 97 controls) from the ophthalmology clinics of Maisonneuve-Rosemont Hospital (Montreal, Canada) to participate in a cross-sectional study from September 2009 until July 2012. Control patients who had normal visual acuity and visual field were recruited from the same clinics. Participants were asked if they limited their activity due to a fear of falling. Visual acuity, contrast sensitivity, and visual field were measured and the medical record was reviewed. RESULTS Between 40% and 50% of patients with eye disease reported activity limitation due to a fear of falling compared with only 16% of controls with normal vision. After adjustment for age, sex, race, number of comorbidities, cognition, and lens opacity, the Fuchs groups was most likely to report activity limitation due to a fear of falling (odds ratio [OR] = 3.07; 95% confidence interval [CI], 1.33-7.06) followed by the glaucoma group (OR = 2.84; 95% CI, 1.36-5.96) and the AMD group (OR = 2.42; 95% CI, 1.09-5.35). Contrast sensitivity best explained these associations. CONCLUSIONS Activity limitation due to a fear of falling is very common in older adults with visually impairing eye disease. Although this compensatory strategy may protect against falls, it may also put people at risk for social isolation and disability.

Incidence and progression of lens opacities: Effect of hormone replacement therapy and reproductive factors

Background: Hormone replacement therapy (HRT) is associated in cross-sectional studies with a decreased prevalence of lens opacities. We explored the associations of HRT and reproductive factors with the incidence and progression of lens opacities over a 2-year period. Methods: Data were derived from 1458 women ages 65 years and older from the Salisbury Eye Evaluation population-based prospective cohort study in Salisbury, MD, 1993–1997. Results: HRT was not associated with incident nuclear, cortical, or posterior subcapsular opacities, or with progression of nuclear or cortical opacification. Women who had an early menopause had a higher risk of nuclear progression, whereas those who had a later menopause had a lower risk (linear trend P = 0.013). Other variables related to reproduction, such as oral contraceptive use, age at menarche, number of births, and history of hysterectomy, were not associated with any of the outcomes. Conclusions: These data suggest no evidence of protection against the incidence or progression of lens opacities with HRT.

Cataract-related vision loss and depression in a cohort of patients awaiting cataract surgery

OBJECTIVE As provinces consider what an acceptable cataract surgery wait time should be, research is needed on the risk of adverse events, such as depression, while waiting for care. We sought to determine whether worse visual acuity is related to depressive symptoms in patients waiting to have cataract surgery. DESIGN Cohort study. PARTICIPANTS Six hundred seventy-two patients awaiting cataract surgery were recruited from Maisonneuve-Rosemont Hospital in Montreal, Que. METHODS About 2 weeks before surgery and 4 months after surgery, patients completed the Visual Function-14 questionnaire, a measure of the self-report of difficulty performing visual tasks, and the 30-item Geriatric Depression Scale. Patients were also asked about systemic and ocular comorbidities. Visual acuity was measured with pinhole correction. Date of entry onto the hospital waiting list and date of cataract surgery were recorded. RESULTS Forty-one percent of patients had visual acuity of 6/18 or worse in the surgical eye, whereas 26% showed signs of depression before surgery (Geriatric Depression Scale-30 > or = 10). In a logistic regression model, those with visual acuity < or = 6/18 in their surgical eye had a 59% higher adjusted odds of depression (odds ratio 1.59, 95% CI 1.09-2.33). There was statistically significant evidence that the relationship between visual acuity and depression was mediated by greater reported difficulty on the Visual Function-14 (p < 0.05). CONCLUSIONS Patients with worse visual acuity were more likely to be depressed while waiting for cataract surgery. Shortening the wait time for cataract surgery, especially for those with worse vision, could potentially reduce the risk or shorten the duration of depression.

Hormone Replacement Therapy, Reproductive Factors, and Age-Related Macular Degeneration: The Salisbury Eye Evaluation Project

Purpose: To evaluate a potential relationship between hormone replacement therapy (HRT), reproductive factors and age-related macular degeneration (AMD). Methods: 1,458 female participants (age 65–84) from the Salisbury Eye Evaluation study were available for this cross-sectional analysis. AMD outcomes were identified by reading center assessment of fundus photographs. Results: Women who currently used HRT had a lower adjusted odds of large drusen (> 125 μ m) (OR = 0.5, 95% CI 0.2–1.0). Use of HRT was not statistically significantly associated with the prevalence of early AMD or advanced AMD, although the odds ratios were all much less than 1. Women who had had an increased number of births had a greater prevalence of large drusen (test of linear trend, p = 0.03). Conclusions: Current use of HRT was associated with a lower odds of large drusen, which may be predictive of advanced AMD. No statistically significant correlations were found between HRT or reproductive factors and early or advanced AMD.

Gender differences in mobility disability during young, middle and older age in West African adults

Abstract The objective of this study was to assess the prevalence and the contribution of socio-demographic factors and chronic diseases to mobility disability in West African countries. Data were obtained from the World Health Survey (2002–2003) in which adults≥18 years participated, from Burkina Faso (n=4822), Mali (n=4230) and Senegal (n=3197). Participants reporting mild, moderate, severe, extreme difficulty or inability to move around were defined as having mobility disability. All estimates were corrected for sampling design. Association measures were estimated using logistic regression methods. Mobility disability was frequent at young ages (35–44 years old) in men and women, respectively: 17% and 23% in Burkina Faso, 12% and 23% in Mali and 22% and 34% in Senegal. Women had higher odds of mobility difficulty than men at every age group in the three countries: 1.34 (95%CI 1.06; 1.70) in Burkina Faso; 2.33 (95% CI 1.84; 2.71) in Mali and 1.82 (95%CI 1.41; 2.36) in Senegal. Controlling for socio-economic factors and chronic disease, these odds changed respectively to 0.94 (95%CI 0.70; 1.25), 2.19 (95%CI 1.61; 2.96) and 1.90 (95%CI 1.27; 2.84). These results constitute a benchmark for the study of trends of mobility disability in West Africa and could be used by policy planners.