A low-vision rehabilitation program for patients with mild cognitive deficits

Assessing optimal colour and illumination to facilitate reading: an analysis of print size

PURPOSE

This study examined how optimal colour/illumination conditions and the efficacy of the iPad, LuxIQ and Smart Bulb varied as a function of print size in younger, older and visually impaired adults.

METHODS

Participants with visual impairments and simulated low vision (SLV) read the MNRead using the iPad, LuxIQ and Smart Bulb.

RESULTS

In the impairment condition at 1.20 logMAR, the iPad (M = 9.49, 95% CI [3.18, 19.42]) and LuxIQ (M = 15.95, 95% CI [9.54, 24.86]) improved the reading speeds. At 0.80 logMAR (SLV), all devices improved reading speeds of older adults (iPad (M = 28.70, 95% CI [14.65, 42.51]); LuxIQ (M = 49.63, 95% CI [30.04, 69.68]); Smart Bulb (M = 23.11, 95% CI [3.33, 42.11])), but in younger adults only the LuxIQ (M = 13.04, 95% CI [3.21, 21.27]) did so. In the impairment condition, the iPad (M = 5.54, 95% CI [0.31, 12.13]) and LuxIQ (M = 13.90, 95% CI [7.88, 23.49]) improved reading speeds. In the SLV condition, age was a significant predictor of reading speed at 1.20 logMAR (F_3,164  = 10.74, p < 0.001, Adj. R²  = 0.16). At 0.80 logMAR, age and luminance, but not colour, were significant predictors (F_3,164  = 52.52, p < 0.001, Adj. R²  = 0.49). In the impairment condition, both age and lux were significant predictors of reading speed at 1.20 (F_3,85  = 7.14, p < 0.001, Adj. R²  = 0.20) and 0.80 logMAR (F_3,85  = 7.97, p < 0.001, Adj. R²  = 0.22), but colour was not.

CONCLUSIONS

Light source effectiveness and optimal colour/illumination vary as a function of print size. It appears that print size is the most important factor for improving reading speed. As print size decreases, luminance becomes crucial, and only at the smallest print sizes does the effect of colour become useful.

Self-reported dual sensory impairment, dementia, and functional limitations in Medicare beneficiaries

BACKGROUND

Vision and hearing impairments often co-exist with dementia, and all are independently associated with limitations in daily activities. Our aim was to examine the association of dual sensory impairment with functional limitations, and further examine the combined estimated association of sensory impairment and dementia with these functional limitations.

METHODS

Cross-sectional analysis of the National Health and Aging Trends Study (NHATS), a population-based cohort of Medicare beneficiaries, was performed. Participants were selected from the 2015 round. Survey weighted Poisson regression models adjusted for dementia, demographics, and health status variables examined the association of self-reported dual sensory impairment (no sensory impairment, single sensory impairment, dual sensory impairment) with scores of limitations in mobility, self-care, and household activities. Models were repeated to take into account the combined effects of dual sensory impairment and dementia.

RESULTS

Overall, 7124 participants representative of Medicare beneficiaries 65 years or older were included. Of them, 43.9% were 75 years or older and 55.3% were female. Older adults with dual sensory impairment had greater limitations with mobility (prevalence rate ratio [PRR] = 1.45, 95% CI = 1.28-1.63), self-care (PRR = 1.41, 95% CI = 1.25-1.59), and household activities (PRR = 1.54, 95% CI = 1.37-1.72) compared with those without sensory impairment. They also had greater limitations than those with a single sensory impairment across the different activity categories. In models taking into account the combined estimated effect of both sensory impairment and dementia, those with dual sensory impairment and dementia had greater limitations than those without sensory impairment or dementia in each category (mobility: PRR = 1.85, 95% CI = 1.59-2.14, self-care: PRR = 1.86, 95% CI = 1.59-2.18, household: PRR = 2.41, 95% CI = 2.09-2.77).

CONCLUSIONS

Older adults with dual sensory impairment had greater functional limitations compared with those without sensory impairment and those with a single sensory impairment. Strategies to improve visual and/or hearing function (e.g., sensory aids, rehabilitation) could potentially help prevent or minimize disability, even among those with dementia.

The Nexus of Sensory Loss, Cognitive Impairment, and Functional Decline in Older Adults: A Scoping Review

BACKGROUND AND OBJECTIVES

The prevalence of cognitive impairment and sensory loss in hearing or vision increases with age. Based on the Information Processing Model, cognitive impairment coupled with sensory loss may exacerbate disability in late life. Yet this issue has not been systematically studied. The purpose of this scoping review was to examine the literature that studied the relationship between cognitive impairment, sensory loss, and activities of daily living in older adults.

RESEARCH DESIGN AND METHODS

Two reviewers independently screened 1,410 studies identified from five electronic databases (Medline, EMBASE, PsycINFO, CINHAL, and the Web of Science). The search was completed in June 2020. A study was eligible if it included measurements of cognitive function, vision or hearing, and activities of daily living. Additionally, the data analyses must address how cognitive impairment and sensory loss are related to the performance of activities of daily living.

RESULTS

The final review included 15 studies. Findings show an additive effect of cognitive impairment and sensory loss on the activities of daily living. Cognitive impairment or vision loss independently relates to the decline in activities of daily living. Hearing loss relates to the decline only when the loss is severe, or if the daily task is hearing specific.

DISCUSSION AND IMPLICATIONS

Older adults with coexisting sensory loss and cognitive impairment have the highest risk or prevalence of disability, comparing to cognitive impairment or sensory loss alone. This finding highlights the importance of developing interventions to reduce the risk of disability for older adults experiencing multiple impairments.

Cognitive Impairment among Veterans in Outpatient Vision Rehabilitation

SIGNIFICANCE

Outpatient vision rehabilitation improves function in veterans with vision impairment, but the prevalence of cognitive impairment and the degree to which it may affect rehabilitation outcomes in the Veterans Affairs system are unknown.

PURPOSE

The purpose of this study was to determine the prevalence of cognitive impairment among veterans receiving outpatient vision rehabilitation in the Veterans Affairs system and compare the benefits of rehabilitation in veterans with and without cognitive impairment.

METHODS

We conducted cognitive assessments and a nested longitudinal cohort study in veterans with eye disorders at two outpatient rehabilitation sites. Cognition was assessed with the Modified Telephone Interview for Cognitive Status administered in person. Eligible veterans and their companions in the longitudinal study responded to questions about the veteran's function at baseline and 90 days later. Visual function was measured with the 48-item Low Vision Visual Function Questionnaire (LV-VFQ-48) and items from the Activity Inventory.

RESULTS

Of 291 veterans assessed (mean ± standard deviation age, 78.2 ± 12 years), 136 (46.7%) were cognitively intact (Modified Telephone Interview for Cognitive Status scores, ≥33), whereas 58 (19.9%) had borderline scores of 30 to 32, 82 (28.2%) had scores suggesting mild/moderate cognitive impairment (scores of 20 to 29), and 15 (5.2%) had scores suggesting severe cognitive impairment (score of <20). After 90 days, mean LV-VFQ-48 reading scores tended to improve in veterans with (n = 21) and without (n = 28) cognitive impairment. The magnitude of self-reported improvement in LV-VFQ-48 scores was greater among cognitively intact, compared with cognitively impaired, veterans (effect size, 0.56 for reading; 0.71 for visual motor). Veterans and companions reported similar 90-day reduction in difficulty with the veterans' top 3 Activity Inventory goals, regardless of cognitive status.

CONCLUSIONS

Approximately one in three veterans referred to outpatient vision rehabilitation has detectable cognitive impairment, yet many still experience functional improvements. Future research should determine best practices to accommodate challenges associated with cognitive impairment in vision rehabilitation and to track clinically meaningful outcomes.

Interventions Within the Scope of Occupational Therapy Practice to Improve Performance of Daily Activities for Older Adults With Low Vision: A Systematic Review

IMPORTANCE

The prevalence of low vision increases with age. Low vision has detrimental effects on older adults' independence.

OBJECTIVE

To identify the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance in daily activities for older adults with low vision.

DATA SOURCES

Literature published between 2010 and 2017 was searched in CINAHL, Cochrane Databases, MEDLINE, OTseeker, and PsycINFO.

STUDY SELECTION AND DATA COLLECTION

The authors screened and appraised studies following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Studies were eligible if the participants' mean age was 55 yr or older, the level of evidence was Level III or higher, the intervention was within the scope of occupational therapy practice, and the outcome measures assessed the performance of daily activities.

FINDINGS

Fourteen studies met the review criteria. Three intervention themes were identified: low vision rehabilitation services (n = 6), self-management approach (n = 6), and tango (n = 2). Moderate evidence was found for low vision rehabilitation services. Low evidence was found for using the self-management approach or adding the self-management approach to existing low vision rehabilitation services. Low evidence was found for tango.

CONCLUSION AND RELEVANCE

This systematic review supports the use of low vision rehabilitation services as an effective approach. Occupational therapy practitioners are encouraged to be part of multidisciplinary teams that offer comprehensive low vision evaluations and multicomponent services.

WHAT THIS ARTICLE ADDS

Low vision rehabilitation that offers multidisciplinary services, including occupational therapy, is effective in promoting independence among older adults with low vision.

Occupational Therapy Practice Guidelines for Older Adults With Low Vision

Importance: The aging of the population is generating increased demand for occupational therapy practitioners to address the occupational performance of those experiencing low vision.

Objective: This Practice Guideline, which is informed by systematic reviews on interventions for older adults with low vision, is meant to serve as a reference for occupational therapy practitioners to guide best practice in service delivery, improve quality of care, enhance consumer satisfaction, and justify occupational therapy services to external stakeholders. Interventions included in this guideline address performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs), reading, and leisure and social participation.

Method: We examined, synthesized, and integrated the results of three systematic reviews into recommendations for practice, education, and research.

Results: Thirty-eight articles were included in the systematic reviews, which served as the basis for clinical recommendations. A case study describes translation and application of the recommendations to clinical practice.

Conclusions and Recommendations: Strong evidence supports the role of occupational therapy for older adults with low vision. On the basis of the evidence, we recommend routine use of low vision rehabilitation for ADL and IADL impairments, multicomponent interventions to improve ADL and IADL performance and leisure and social participation, stand-based electronic magnification to enhance reading, and visual skills training to enhance reading for clients with a central field impairment. We recommend using client-centered problem-solving training to enhance ADL and IADL performance, reading, and leisure and social participation. Mainstream technology may be considered for use on a case-by-case basis to enhance reading performance. Finally, adapted tango may be considered for use on a case-by-case basis to enhance ADL and IADL performance and leisure and social participation.

What This Article Adds: This Practice Guideline provides a summary of the current evidence supporting occupational therapy intervention for older adults with low vision. It summarizes the emerging literature supporting the use of mainstream technology and provides additional support for the use of multicomponent intervention strategies.

Interventions for hearing and vision impairment to improve outcomes for people with dementia: a scoping review

ABSTRACTBackground:Age-related hearing and vision problems are common among people with dementia and are associated with poorer function, reduced quality of life and increased caregiver burden. Addressing sensory impairments may offer an opportunity to improve various aspects of life for people with dementia.

METHODS

Electronic databases were searched using key terms dementia, hearing impairment, vision impairment, intervention, and management. Database searches were supplemented by hand searching bibliographies of papers and via consultation with a network of health professional experts. Studies were eligible for inclusion if they included adults aged over 50 with dementia with adult-onset hearing or vision impairment who had received a hearing or vision intervention in relation to cognitive function, rate of decline, psychiatric symptoms, hearing/vision-related disability, quality of life, and/or caregiver burden outcomes. A range of study designs were included. Results were summarized descriptively according to level of evidence and effect sizes calculated where possible. Risk of bias was assessed using Downs and Black's (1998) checklist. The development of the intervention was summarized according to the CReDECI2 scheme. PROSPERO review registration number 2016:CRD42016039737.

RESULTS

Twelve papers describing hearing interventions and five papers describing vision interventions were included. Most were of low to moderate quality. One high quality randomized controlled trial of a hearing aid intervention was identified. Hearing interventions included provision of hearing aids, assistive listening devices, communication strategies, hearing aid trouble shooting, and cochlear implantation. Vision interventions included prism lenses, rehabilitation training, and cataract surgery. There was no consistent evidence for the positive impact of hearing/vision interventions on cognitive function, rate of cognitive decline, quality of life, or caregiver burden.

CONCLUSION

Sensory interventions may promote better outcomes, but there is a need for properly powered, controlled trials of hearing and vision interventions on outcomes relevant to people living with dementia.

Recommendations for successful sensory screening in older adults with dementia in long-term care: a qualitative environmental scan of Canadian specialists

OBJECTIVES

This study aimed to identify screening tools, technologies and strategies that vision and hearing care specialists recommend to front-line healthcare professionals for the screening of older adults in long-term care homes who have dementia.

SETTING

An environmental scan of healthcare professionals took place via telephone interviews between December 2015 and March 2016. All interviews were audio recorded, transcribed, proofed for accuracy, and their contents thematically analysed by two members of the research team.

PARTICIPANTS

A convenience sample of 11 professionals from across Canada specialising in the fields of vision and hearing healthcare and technology for older adults with cognitive impairment were included in the study.

OUTCOME MEASURES

As part of a larger mixed-methods project, this qualitative study used semistructured interviews and their subsequent content analysis.

RESULTS

Following a two-step content analysis of interview data, coded citations were grouped into three main categories: (1) barriers, (2) facilitators and (3) tools and strategies that do or do not work for sensory screening of older adults with dementia. We report on the information offered by participants within each of these themes, along with a summary of tools and strategies that work for screening older adults with dementia.

CONCLUSIONS

Recommendations from sensory specialists to nurses working in long-term care included the need for improved interprofessional communication and collaboration, as well as flexibility, additional time and strategic use of clinical intuition and ingenuity. These suggestions at times contradicted the realities of service provision or the need for standardised and validated measures.

Improving hearing and vision in dementia: protocol for a field trial of a new intervention

INTRODUCTION

Quality of life and other key outcomes may be improved by optimising hearing and vision function in people living with dementia. To date, there is limited research assessing the efficacy of interventions aimed at improving hearing and vision in people with dementia. Here, we outline a protocol to field test a newly developed home-based intervention, designed to optimise sensory functioning in people with dementia in three European sites. The results of this study will inform the design and conduct of a full-scale randomised controlled trial (RCT) in five European sites.

METHODS AND ANALYSIS

In this multisite, single arm, open label, feasibility study, participants with dementia (n=24) will be assessed for hearing and vision impairments and be prescribed a hearing aid and/or glasses. Each participant will have a study partner ('dyads'). A subset of dyads will receive 'sensory support' from a 'sensory support therapist', comprising home visits over 12 weeks. The therapist will offer the following intervention: adherence support for corrective devices; adaptations to the home environment to facilitate sensory function; communication training; and referral to community-based support services. The primary outcomes will be process measures assessing the feasibility, tolerability and acceptability of: (1) the intervention components; (2) the method of implementation of the intervention and (3) the study procedures, including outcome assessment measures. Quantitative data will be collected at baseline and follow-up. Qualitative data using semistructured interviews will be collected postintervention and weekly, using participant diaries. Finally, we will explore a model of cost-effectiveness to apply in the subsequent full-scale trial. This feasibility study is a necessary step in the development of a complex, individualised, psychosocial intervention. The data gathered will allow logistical and theoretical processes to be refined in preparation for a full-scale RCT.

ETHICS AND DISSEMINATION

Ethical approval was obtained in all three participating countries. Results of the field trial will be submitted for publication in a peer-reviewed journal.

Sensorineural Organs Dysfunction and Cognitive Decline: A Review Article

Vision, hearing, olfaction, and cognitive function are essential components of healthy and successful aging. Multiple studies demonstrate relationship between these conditions with cognitive function. The present article focuses on hearing loss, visual impairment, olfactory loss, and dual sensory impairments in relation to cognitive declination and neurodegenerative disorders. Sensorineural organ impairment is a predictive factor for mild cognitive impairment and neurodegenerative disorders in the elderly. We recommend early detection of sensorineural dysfunction by history, physical examination, and screening tests. Assisted device and early cognitive rehabilitation may be beneficial. Future research is warranted in order to explore advanced treatment options and method to slow progression for cognitive declination and sensorineural organ impairment.

Client and therapist perspectives on the influence of low vision and chronic conditions on performance and occupational therapy intervention

OBJECTIVE

We explored how vision loss and comorbid chronic conditions influence occupational therapy intervention by gathering perspectives from occupational therapists treating clients with low vision and from older adults with low vision.

METHOD

We surveyed 59 occupational therapists on the frequency of comorbidities in their clients and their influence on low vision intervention. Eight older adults with low vision participated in in-depth interviews and observations on the influence of low vision and comorbidities on their occupational performance. Conclusions reflect data analysis from both methods.

RESULTS

The occupational therapists modified low vision interventions to address the added effect of each comorbidity. Modifications included more treatment sessions, home visits, referrals to other professions, and provision of strategies to address comorbidities. The older adults viewed vision loss as a stronger influence than comorbidities on independence in daily occupations.

CONCLUSION

Both vision loss and comorbidities influence occupational performance, supporting the need for interventions to address both conditions.

Health coaching for glaucoma care: a pilot study using mixed methods

Introduction

Adherence to glaucoma medications is essential for successful treatment of the disease but is complex and difficult for many of our patients. Health coaching has been used successfully in the treatment of other chronic diseases. This pilot study explores the use of health coaching for glaucoma care.

Methods

A mixed methods study design was used to assess the health coaching intervention for glaucoma patients. The health coaching intervention consisted of four to six health coaching sessions with a certified health coach via telephone. Quantitative measures included demographic and health information, adherence to glaucoma medications (using the visual analog adherence scale and medication event monitoring system), and an exit survey rating the experience. Qualitative measures included a precoaching health questionnaire, notes made by the coach during the intervention, and an exit interview with the subjects at the end of the study.

Results

Four glaucoma patients participated in the study; all derived benefits from the health coaching. Study subjects demonstrated increased glaucoma drop adherence in response to the coaching intervention, in both visual analog scale and medication event monitoring system. Study subjects’ qualitative feedback reflected a perceived improvement in both eye and general health self-care. The subjects stated that they would recommend health coaching to friends or family members.

Conclusion

Health coaching was helpful to the glaucoma patients in this study; it has the potential to improve glaucoma care and overall health.

Insights into inpatients with poor vision: A high value proposition

BACKGROUND

Vision impairment is an under-recognized risk factor for adverse events among hospitalized patients, yet vision is neither routinely tested nor documented for inpatients. Low-cost ($8 and up) nonprescription "readers" may be a simple, high-value intervention to improve inpatients' vision. We aimed to study initial feasibility and efficacy of screening and correcting inpatients' vision.

METHODS

From June 2012 through January 2014 we began testing whether participants' vision corrected with nonprescription lenses for eligible participants failing a vision screen (Snellen chart) performed by research assistants (RAs). Descriptive statistics and tests of comparison, including t tests and χ(2) tests, were used when appropriate. All analyses were performed using Stata version 12 (StataCorp, College Station, TX).

RESULTS

Over 800 participants' vision was screened (n = 853). Older (≥65 years; 56%) participants were more likely to have insufficient vision than younger (<65 years; 28%; P < 0.001). Nonprescription readers corrected the majority of eligible participants' vision (82%, 95/116).

DISCUSSION

Among an easily identified subgroup of inpatients with poor vision, low-cost readers successfully corrected most participants' vision. Hospitalists and other clinicians working in the inpatient setting can play an important role in identifying opportunities to provide high-value care related to patients' vision.

Correlation between visual acuity and cognitive functions

A possible association between visual acuity (VA) and dementia was investigated in 2716 subjects who were aged between 53 and 102 at first visit and had varying degrees of dementia. Better VA was found to be significantly correlated with a lower dementia level (person coefficient range 0.146-0.261 over 10 years of follow-up, all correlations are significant, p<0.0001) as well as with a higher global cognitive score (person coefficient range -0.254 to -0.318 over 10 years of follow-up, all correlations are significant, p<0.0001), a grade encompassing 19 different cognitive tests. This correlation remained significant after adjustment for age, years of education, gender, use of ophthalmic drugs and years of follow-up.