John E. Crews

Vision Impairment and Hearing Loss Among Community-Dwelling Older Americans: Implications for Health and Functioning

OBJECTIVES We investigated the health, activity, and social participation of people aged 70 years or older with vision impairment, hearing loss, or both. METHODS We examined the 1994 Second Supplement on Aging to determine the health and activities of these 3 groups compared with those without sensory loss. We calculated odds ratios and classified variables according to the International Classification of Functioning, Disability and Health framework. RESULTS Older people with only hearing loss reported disparities in health, activities, and social roles; those with only vision impairment reported greater disparities; and those with both reported the greatest disparities. CONCLUSIONS A hierarchical pattern emerged as impairments predicted consistent disparities in activities and social participation. This populations patterns of health and activities have public health implications.

Framing the Public Health of Caregiving

Caregiving has only recently been acknowledged by the nation as an important topic for millions of Americans. A psychological or sociological approach to care-giving services has been most often applied, with little attention to the population-based public health outcomes of caregivers. We conceptualize caregiving as an emerging public health issue involving complex and fluctuating roles. We contend that caregiving must be considered in the context of life span needs that vary according to the ages, developmental levels, mental health needs, and physical health demands of both caregivers and care recipients.

Association between depression and functional vision loss in persons 20 years of age or older in the United States, NHANES 2005-2008.

IMPORTANCE This study provides further evidence from a national sample to generalize the relationship between depression and vision loss to adults across the age spectrum. Better recognition of depression among people reporting reduced ability to perform routine activities of daily living due to vision loss is warranted. OBJECTIVES To estimate, in a national survey of US adults 20 years of age or older, the prevalence of depression among adults reporting visual function loss and among those with visual acuity impairment. The relationship between depression and vision loss has not been reported in a nationally representative sample of US adults. Previous studies have been limited to specific cohorts and predominantly focused on the older population. DESIGN The National Health and Nutrition Examination Survey (NHANES) 2005-2008. SETTING A cross-sectional, nationally representative sample of adults, with prevalence estimates weighted to represent the civilian, noninstitutionalized US population. PARTICIPANTS A total of 10 480 US adults 20 years of age or older. MAIN OUTCOME MEASURES Depression, as measured by the 9-item Patient Health Questionnaire depression scale, and vision loss, as measured by visual function using a questionnaire and by visual acuity at examination. RESULTS In 2005-2008, the estimated crude prevalence of depression (9-item Patient Health Questionnaire score of ≥10) was 11.3% (95% CI, 9.7%-13.2%) among adults with self-reported visual function loss and 4.8% (95% CI, 4.0%-5.7%) among adults without. The estimated prevalence of depression was 10.7% (95% CI, 8.0%-14.3%) among adults with presenting visual acuity impairment (visual acuity worse than 20/40 in the better-seeing eye) compared with 6.8% (95% CI, 5.8%-7.8%) among adults with normal visual acuity. After controlling for age, sex, race/ethnicity, marital status, living alone or not, education, income, employment status, health insurance, body mass index, smoking, binge drinking, general health status, eyesight worry, and major chronic conditions, self-reported visual function loss remained significantly associated with depression (overall odds ratio, 1.9 [95% CI, 1.6-2.3]), whereas the association between presenting visual acuity impairment and depression was no longer statistically significant. CONCLUSIONS AND RELEVANCE Self-reported visual function loss, rather than loss of visual acuity, is significantly associated with depression. Health professionals should be aware of the risk of depression among persons reporting visual function loss.

Vision Health Disparities in the United States by Race/Ethnicity, Education, and Economic Status: Findings From Two Nationally Representative Surveys

PURPOSE To assess vision health disparities in the United States by race/ethnicity, education, and economic status. DESIGN Cross-sectional, nationally representative samples. METHODS We used national survey data from the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey (NHIS). Main outcome measures included, from NHANES, age-related eye diseases (ie, age-related macular degeneration [AMD], cataract, diabetic retinopathy [DR], glaucoma) and from NHIS, eye care use (ie, eye doctor visits and cannot afford eyeglasses when needed) among those with self-reported visual impairment. The estimates were age- and sex-standardized to the 2000 US Census population. Linear trends in the estimates were assessed by weighted least squares regression. RESULTS Non-Hispanic whites had a higher prevalence of AMD and cataract surgery than non-Hispanic blacks, but a lower prevalence of DR and glaucoma (all P < .001 in NHANES 2005-2008). From 1999 to 2008, individuals with less education (ie, high school) and lower income (poverty income ratio [PIR] <1.00 vs ≥ 4.00) were consistently less likely to have had an eye care visit in the past 12 months compared with their counterparts (all P < .05). During this period, inability to afford needed eyeglasses increased among non-Hispanic whites and Hispanics (trend P = .004 and P = .007; respectively), those with high school education (trend P = .036), and those with PIR 1.00-1.99 (trend P < .001). CONCLUSIONS Observed vision health disparities suggest a need for educational and innovative interventions among socioeconomically disadvantaged groups.

Effects of depressive symptoms on health behavior practices among older adults with vision loss.

OBJECTIVE The authors examined the interface between visual impairment and depressive symptoms on health behaviors, self-care, and social participation among adults ages 65 and older. METHOD The authors analyzed data from the 1997-2004 National Health Interview Survey on visual impairment and depressive symptoms for 49,278 adults ages 65 and older, comparing visually impaired adults (n = 8,787) with and without depressive symptoms with a reference group of adults with neither condition (n = 3,136) for outcome measures: physical health, health behaviors, and difficulties with self-care and social participation. RESULTS Adults with visual impairment and severe depressive symptoms were more likely than adults with neither condition to smoke (14.9%, adjusted odds ratio [AOR] = 1.6), be obese (28.2%, AOR = 1.9), be physically inactive (80.5%, AOR = 3.0), have fair-poor health (76.0%, AOR = 26.5), and have difficulties with self-care (27.9%, AOR = 11.8) and social participation (52.1%, AOR = 10.9). DISCUSSION AND CONCLUSIONS Older visually impaired adults with depressive symptoms are vulnerable to health decline and further disablement without timely interventions that target smoking cessation, healthy eating, and increased physical activity.

Disparities in Adult Vision Health in the United States

PURPOSE To review the existing knowledge on vision health disparities in major adult vision health outcomes (age-related macular degeneration, diabetic retinopathy, glaucoma, cataract, refractive errors) and visual impairment and to identify knowledge gaps as related to the development of enhanced vision health surveillance in the United States. DESIGN Literature review. METHODS Analysis of relevant publications in the peer-reviewed literature. RESULTS Prevalence data on vision health outcomes is limited to findings from a few key population-based studies. Study populations are not representative of all persons living in the United States. Vision loss and visual impairment are more common with age, and there is racial variation in the specific causes of vision loss (underlying health conditions). Women are at greater risk of vision loss than men (even after adjusting for age). Vision-related disability and disparities in visual outcomes are monitored poorly at present. CONCLUSIONS Data to assess and monitor trends in vision health disparities in the United States are not collected presently in a systematic fashion. This lack of data limits public health efforts to overcome barriers to eye care use and to improve vision outcomes.

Disparities in Eye Care Utilization Among the United States Adults With Visual Impairment: Findings From the Behavioral Risk Factor Surveillance System 2006-2009

PURPOSE To estimate the prevalence of annual eye care among visually impaired United States residents aged 40 years or older, by state, race/ethnicity, education, and annual income. DESIGN Cross-sectional study. METHODS In analyses of 2006-2009 Behavioral Risk Factor Surveillance System data from 21 states, we used multivariate regression to estimate the state-level prevalence of yearly eye doctor visit in the study population by race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and other), annual income (≥

Barriers to Eye Care Among People Aged 40 Years and Older With Diagnosed Diabetes, 2006–2010

35,000 and <

Health-Related Quality of Life Among People Aged ≥65 Years with Self-reported Visual Impairment: Findings from the 2006–2010 Behavioral Risk Factor Surveillance System

35,000), and education (< high school, high school, and > high school). RESULTS The age-adjusted state-level prevalence of yearly eye doctor visits ranged from 48% (Missouri) to 69% (Maryland). In Alabama, Colorado, Indiana, Iowa, New Mexico, and North Carolina, the prevalence was significantly higher among respondents with more than a high school education than among those with a high school education or less (P < .05). The prevalence was positively associated with annual income levels in Alabama, Georgia, New Mexico, New York, Texas, and West Virginia and negatively associated with annual income levels in Massachusetts. After controlling for age, sex, race/ethnicity, education, and income, we also found significant disparities in the prevalence of yearly eye doctor visits among states. CONCLUSION Among visually impaired US residents aged 40 or older, the prevalence of yearly eye examinations varied significantly by race/ethnicity, income, and education, both overall and within states. Continued and possibly enhanced collection of eye care utilization data, such as we analyzed here, may help states address disparities in vision health and identify population groups most in need of intervention programs.

Disability and its correlates with chronic morbidities among U.S. adults aged 50−< 65 years☆

OBJECTIVE We examine barriers to receiving recommended eye care among people aged ≥40 years with diagnosed diabetes. RESEARCH DESIGN AND METHODS We analyzed 2006–2010 Behavioral Risk Factor Surveillance System data from 22 states (n = 27,699). Respondents who had not sought eye care in the preceding 12 months were asked the main reason why. We categorized the reasons as cost/lack of insurance, no need, no eye doctor/travel/appointment, and other (meaning everything else). We used multinomial logistic regression to control for race/ethnicity, education, income, and other selected covariates. RESULTS Among adults with diagnosed diabetes, nonadherence to the recommended annual eye examinations was 23.5%. The most commonly reported reasons for not receiving eye care in the preceding 12 months were “no need” and “cost or lack of insurance” (39.7 and 32.3%, respectively). Other reasons were “no eye doctor,” “no transportation” or “could not get appointment” (6.4%), and “other” (21.5%). After controlling for covariates, adults aged 40–64 years were more likely than those aged ≥65 years (relative risk ratio [RRR] = 2.79; 95% CI 2.01–3.89) and women were more likely than men (RRR = 2.33; 95% CI 1.75–3.14) to report “cost or lack of insurance” as their main reason. However, people aged 40–64 years were less likely than those aged ≥65 years to report “no need” (RRR = 0.51; 95% CI 0.39–0.67) as their main reason. CONCLUSIONS Addressing concerns about “cost or lack of insurance” for adults under 65 years and “no perceived need” among those 65 years and older could help improve eye care service utilization among people with diabetes.