Ruth M. A. van Nispen

A dutch IcF Version of the Activity Inventory: results from Focus Groups with Visually Impaired Persons and Experts

Purpose: To develop a valid and reliable instrument to systematically investigate visual rehabilitation needs of visually impaired older adults, which is compatible with the “International Classification of Functioning, Disability and Health” (ICF) structure: a new Dutch ICF version of the Activity Inventory (D-AI). Methods: The original AI was translated, adjusted and expanded. After studying literature and investigating patient records, focus group discussions were conducted until the input was just confirmatory. Six (n = 41) and seven (n = 50) discussions with patients and professionals respectively contributed to the first draft of the D-AI, which was further improved by professionals. Results: The D-AI now consists of 10 domains, 68 goals and 813 tasks. Goals are organized into the “Activities and Participation” domains of the ICF. The original routing was maintained; only tasks organized under important (0 [not important] to 3 [very important]) and difficult (0 [not difficult] to 4 [impossible]) goals were assessed. Conclusion: Rehabilitation needs can be organized in the “Activities and Participation” domains of the ICF. The D-AI offers a way of systematically assessing and measuring functional limitations and disabilities, and provides detailed information about activities that are needed to perform a certain goal. Focus group discussions with Dutch patients and experts revealed additional items that will probably be relevant for other populations. Involving patients in the first step of the developing process is important to provide face and content validity. The D-AI can prioritize rehabilitation goals by multiplying importance and difficulty scores, which is helpful in formulating a rehabilitation plan.

Stepped care for depression and anxiety in visually impaired older adults: multicentre randomised controlled trial

Study question Is stepped care compared with usual care effective in preventing the onset of major depressive, dysthymic, and anxiety disorders in older people with visual impairment (caused mainly by age related eye disease) and subthreshold depression and/or anxiety? Methods 265 people aged ≥50 were randomly assigned to a stepped care programme plus usual care (n=131) or usual care only (n=134). Supervised occupational therapists, social workers, and psychologists from low vision rehabilitation organisations delivered the stepped care programme, which comprised watchful waiting, guided self help based on cognitive behavioural therapy, problem solving treatment, and referral to a general practitioner. The primary outcome was the 24 month cumulative incidence (seven measurements) of major depressive dysthymic and/or anxiety disorders (panic disorder, agoraphobia, social phobia, and generalised anxiety disorder). Secondary outcomes were change in symptoms of depression and anxiety, vision related quality of life, health related quality of life, and adaptation to vision loss over time up to 24 months’ follow-up. Study answer and limitations 62 participants (46%) in the usual care group and 38 participants (29%) from the stepped care group developed a disorder. The intervention was associated with a significantly reduced incidence (relative risk 0.63, 95% confidence interval 0.45 to 0.87; P=0.01), even if time to the event was taken into account (adjusted hazard ratio 0.57, 0.35 to 0.93; P=0.02). The number needed to treat was 5.8 (3.5 to 17.3). The dropout rate was fairly high (34.3%), but rates were not significantly different for the two groups, indicating that the intervention was as acceptable as usual care. Participants who volunteered and were selected for this study might not be representative of visually impaired older adults in general (responders were significantly younger than non-responders), thereby reducing the generalisability of the outcomes. What this study adds Stepped care seems to be a promising way to deal with depression and anxiety in visually impaired older adults. This approach could lead to standardised strategies for the screening, monitoring, treatment, and referral of visually impaired older adults with depression and anxiety. Funding, competing interests, data sharing Funded by ZonMw InZicht, the Dutch Organisation for Health Research and Development-InSight Society. There are no competing interests. Full dataset and statistical code are available from the corresponding author. Study registrationwww.trialregister.nl NTR3296.

Visual Functioning Questionnaire: reevaluation of psychometric properties for a group of working-age adults

Purpose. The Visual Functioning Questionnaire (VFQ-25) is one of the most widely used measures of vision-related quality of life. However, the questionnaire does not meet some psychometric quality criteria. The objectives of this study were first to obtain the factor structure of the VFQ-25, and second, to obtain interval scales by Rasch analysis. Methods. The questionnaire was administered to 129 visually impaired adults (mean age 42.1 years; range 21 to 67 years). First, the items of the VFQ-25 were subjected to an exploratory factor analysis with Promax rotation. Next, we performed a separate Rasch analysis on each factor. We examined step thresholds and goodness of fit statistics of the items. Finally, we examined differential item functioning. Results. Factor analysis indicated four factors: Near Activities, Distance Activities and Mobility, Mental Health and Dependency, and Pain and Discomfort. They accounted for 46.37% of the total variance. Most items showed some degree of disordering. After collapsing response categories, all items showed ordered thresholds. The Near Activities domain showed excellent fit, whereas the Distance Activities and Mobility domain, the Mental Health and Dependency domain, and the Pain and Discomfort domain had an unsatisfactory fit. There were two items showing uniform differential item functioning. Conclusions. The four-factor structure of the VFQ-25 largely confirms the structure of the questionnaire. However, the results of this study suggest that modifications of the original VFQ-25 structure are necessary.

Stepped-care to prevent depression and anxiety in visually impaired older adults – design of a randomised controlled trial

BackgroundSubthreshold depression and anxiety are common in the growing population of visually impaired older adults and increase the risk of full-blown depressive or anxiety disorders. Adequate treatment may prevent the development of depression or anxiety in this high risk group.Method/designA stepped-care programme was developed based on other effective interventions and focus groups with professionals and patient representatives of three low vision rehabilitation organisations in the Netherlands and Belgium. The final programme consists of four steps: 1) watchful waiting, 2) guided self-help, 3) problem solving treatment, 4) referral to general practitioner. The (cost-)effectiveness of this programme is evaluated in a randomised controlled trial. Patients (N = 230) are randomly assigned to either a treatment group (stepped-care) or a control group (usual care). The primary outcome is the incidence of depressive and anxiety disorders, measured with the Mini International Neuropsychiatric Interview (MINI).DiscussionPreventive interventions for depression and anxiety have received little attention in the field of low vision. A stepped-care programme that focuses on both depression and anxiety has never been investigated in visually impaired older adults before. If the intervention is shown to be effective, this study will result in an evidence based treatment programme to prevent depression or anxiety in patients from low vision rehabilitation organisations. The pragmatic design of the study greatly enhances the generalisability of the results. However, a possible limitation is the difficulty to investigate the contribution of each individual step.Trial registrationIdentifier: NTR3296

Randomized Controlled Trial on the Effects of CCTV Training on Quality of Life, Depression, and Adaptation to Vision Loss

PURPOSE In addition to performance-based measures, vision-related quality of life (QOL) and other subjective measures of psychosocial functioning are considered important outcomes of training in the visually impaired. In a multicenter, masked, randomized controlled trial, subjective effects of training in the use of closed-circuit televisions (CCTV) were investigated. METHODS Patients (n = 122) were randomized either to a treatment group that received usual delivery instructions from the supplier combined with concise outpatient training, or to a control group that received delivery instructions only. Subjective outcomes were the low vision quality-of-life questionnaire (LVQOL), EuroQOL 5 dimensions, adaptation to age-related vision loss (AVL), and the Center of Epidemiologic Studies Depression scales. Linear mixed models were used to investigate treatment effects. Differential effects of patient characteristics were studied by implementing higher order interactions into the models. RESULTS From baseline to follow-up, all patients perceived significantly less problems on the reading and fine work dimension (-28.8 points; P < 0.001) and the adaptation dimension (-4.67 points; P = 0.04) of the LVQOL. However, no treatment effect was found based on the intention-to-treat analysis. CONCLUSIONS This study demonstrated the effect of receiving and using a CCTV on two vision-related QOL dimensions; however, outpatient training in the use of CCTVs had no additional value. (trialregister.nl number, NTR1031.).

Psychosocial interventions to improve mental health in adults with vision impairment: systematic review and meta-analysis

To systematically assess the literature on psychosocial interventions to improve mental health (i.e. depression, anxiety, mental fatigue, loneliness, psychological stress and psychological well‐being) in visually impaired adults (≥18 years).

The incidence and predictors of depressive and anxiety symptoms in older adults with vision impairment: a longitudinal prospective cohort study

Depression and anxiety are highly prevalent in older adults with vision impairment. Because symptoms of depression and anxiety appear to fluctuate, it is important to identify patients who are at risk of developing these symptoms for early diagnosis and treatment. Therefore, the aim of this study was to determine the incidence of subthreshold depression and anxiety, and to investigate predictors of developing symptoms of depression and anxiety in older adults with vision impairment who had no subthreshold depression or anxiety at baseline.

Associations Between Spatial and Temporal Contrast Sensitivity and Reading

PURPOSE To gain insight into the association between optical and neural components of contrast sensitivity (CS), operationalized as spatial CS (optical and neural) or temporal CS (solely neural), and reading speed in a clinical sample of healthy adults of various ages. Furthermore, precision and agreement of the two methods were assessed. METHODS The Mars test and the temporal CS implementation of the C-Quant device were used to measure spatial CS and temporal CS, respectively. Tests were performed with 71 normally sighted adults: mean age 55 (range 18-86) years. Pearsons correlation analyses were performed between spatial CS or temporal CS, and reading speed and partial correlations controlled for age are presented. Precision of the measurement was defined by the coefficient of repeatability and repeated measures standard deviations. Differences between spatial CS and temporal CS values were determined with 95% limits of agreement. RESULTS A correlation was found between reading speed and both spatial CS (r = 0.470; P < .001) and temporal CS (r = 0.258; P = .04); partial correlations controlled for age were r = 0.175 (P = .17) and r = 0.152 (P = .24), respectively. Coefficient of repeatability was 0.13 log units and 0.24 log units for spatial CS and temporal CS test, respectively. A proportional difference of 0.1 log units was found between spatial CS and temporal CS measurements. CONCLUSIONS A significant correlation was found between both spatial CS and temporal CS and reading speed indicating that, besides optical components, neural aspects may be important in defining reading speed. The stronger correlation between spatial CS and reading speed is suggested to reflect a deterioration of both optical and neural factors with increasing age. The coefficients of repeatability for spatial CS and temporal CS found in the present study are in agreement with previous research, and the difference found between the two methods might be attributed to the psychometric differences between the methods.

Prevalence and risk factors of diabetic retinopathy among an elderly population with diabetes in Nepal: the Bhaktapur Retina Study

Aim Diabetic retinopathy (DR) is an emerging cause of blindness in developing countries. This study aimed to explore the prevalence and risk factors of DR in an elderly population in Nepal. Subjects and methods This is a population-based, cross-sectional study. A total of 1860 subjects at the age 60 years and above participated (response rate 88.6%). A detailed history was obtained, presenting and best-corrected visual acuity were measured, and anterior segment and posterior segment examinations were carried out. Blood pressure and random blood sugar were recorded; body mass index was calculated, and abdominal girth was measured. DR was graded by clinical examination using Early Treatment Diabetic Retinopathy Study criteria. Results Diabetes was found in 168 (9%) subjects (mean age 69.6 years), 31 (18.5%) of whom were newly diagnosed. The prevalence of DR was 23.8% (95% confidence interval [CI]: 17.7%–31%) among the persons with diabetes. The prevalence of DR among newly diagnosed subjects with diabetes was 6.5% (95% CI: 0.8%–21.4%). The prevalence of vision-threatening DR was 9.5% (95% CI: 5.5%–15%) and was higher in males. The prevalence of DR was 83.3% (95% CI: 35.9%–99.6%) among those with diabetes for over 20 years. In multivariable logistic regression analysis, duration of diabetes, hypertension, and alcohol consumption were significantly associated with DR. Conclusion DR is a common problem among the elderly population with diabetes in Nepal. The duration of diabetes, hypertension, and alcohol consumption are the risk factors for the development of DR. Strategies have to be developed for timely diagnosis of diabetes and screening for DR.

Economic evaluation of an e-mental health intervention for patients with retinal exudative diseases who receive intraocular anti-VEGF injections (E-PsEYE): protocol for a randomised controlled trial

Introduction Because of the great potential of vascular endothelial growth factor inhibitors (anti-VEGF) for retinal exudative diseases, an increased number of patients receives this treatment. However, during this treatment, patients are subjected to frequent invasive intravitreal injections, and the effects on reversing the process of vision loss are uncertain, which may have negative consequences for patients’ mental health. One in three patients experience at least mild symptoms of depression/anxiety. To support patients in dealing with these symptoms, an e-mental health intervention (called E-PsEYE) has been developed. E-PsEYE is based on cognitive–behavioural therapy (CBT) and contains nine modules. A stepped-care model with three steps will be used to deliver the intervention: (1) providing information and psychoeducation, (2) when symptoms of depression/anxiety persist, guided CBT is offered and supported by social workers from low vision rehabilitation services and (3) when symptoms still persist, patients are referred to their general practitioner. Methods and analysis An economic evaluation from a healthcare and societal perspective will be conducted alongside a multicentre randomised controlled trial in two parallel groups to evaluate whether E-PsEYE is cost-effective in comparison with usual care. Participants (n=174) will be 50 years or older, have retinal exudative diseases, receive anti-VEGF treatment and have mild symptoms of depression/anxiety (assessed prior to randomisation). Main outcome measures are: depression (Patient Health Questionnaire-9), anxiety (Hospital Anxiety and Depression Scale-Anxiety) and quality-adjusted life-years (determined with the Health Utility Index-3 and the EuroQol-5 dimensions). Five measurements take place: at baseline and after 3, 6, 9 and 12 months. Ethics and dissemination The study has been approved by the Medical Ethics Committee of the VU University Medical Centre Amsterdam. It will provide new and essential information on the cost-effectiveness of an innovative intervention for a vulnerable population. Outcomes will be disseminated through peer-reviewed publications and conference presentations. Trial registration http://www.trialregister.nl, identifier: NTR6337.