Self-care tools to treat depressive symptoms in patients with age-related eye disease: a randomized controlled clinical trial

Self-management interventions for quality of life in adults with visual impairment

RATIONALE

Visual impairment is a major health concern that predominantly impacts older adults due to age-related ocular diseases. Visual impairment affects more than 2200 million people worldwide and may lead to functional and psychological decline, emphasizing the need for effective self-management interventions. Self-management interventions aim to enhance individuals' abilities to manage their condition, maintain activities of daily living, and improve overall well-being.

OBJECTIVES

To assess the effects of self-management interventions on quality of life in adults with visual impairment compared with inactive or active (usual care) control interventions.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and two trial registries, together with reference checking and contact with study authors to identify studies that are included in the review. The latest search date was on 19 May 2024.

ELIGIBILITY CRITERIA

We included parallel-group randomized controlled trials (RCTs) comparing multifaceted self-management interventions in adults with acquired visual impairment (including dual sensory impairment).

OUTCOMES

Outcomes assessed were overall and subscores of health-related quality of life (HRQoL) and vision-related quality of life (VRQoL) scores at the end of follow-up, adverse events during the study period, and vision-related living performance measures at the end of follow-up.

RISK OF BIAS

We assessed the risk of bias for three outcomes reported in a summary of findings table using the Cochrane RoB 2 tool.

SYNTHESIS METHODS

We synthesized results for each outcome using meta-analysis where possible, by calculating standardized mean difference (SMD) or mean difference (MD) with 95% confidence interval (CI) for continuous outcomes and risk ratio (RR) with 95% CIs for dichotomous outcomes. Where this was not possible due to the nature of the data, we provided a narrative summary of the results. We used GRADE to assess certainty of evidence for prespecified outcomes.

INCLUDED STUDIES

We included 20 parallel-group RCTs that enrolled 3151 participants. The size of studies ranged from 30 to 323 participants with a median of 153 participants. Studies were conducted in Asia (two studies), Australia (two), Europe (six), and North America (10) in academic medical centers, hospitals, low-vision clinics, private practice, rehabilitation centers, and Veterans Affairs medical facilities. The participants were older adults with a mean age across the included studies ranging from 60 to 84 years. The mean logarithm of the minimum angle of resolution (logMAR) visual acuity ranged from 0.15 to 1.11. Age-related macular degeneration was the predominant cause of low vision in 15 studies. We did not identify any eligible studies for adults with dual sensory impairment. One study was funded by industry, whereas others received a research grant or support from a non-profit organization or foundation. Multifaceted self-management interventions included in this review were diverse. The control group was placed on a wait list, while other active controls included usual care, optical aids, or low-vision rehabilitation.

SYNTHESIS OF RESULTS

We rated the overall risk of bias of included studies as low or some concerns. The meta-analysis revealed consistent findings across different outcomes and comparisons. For HRQoL, evidence suggests that self-management intervention may result in little to no difference in HRQoL (change score: SMD -0.09, 95% CI -0.33 to 0.15; I2 = 46%; 3 studies, 568 participants; final value: SMD -0.15, 95% CI -0.38 to 0.08; I2 = 31%; 3 studies, 459 participants; low-certainty evidence). This finding remained consistent regardless of whether wait list or active control was the comparator. For VRQoL, multifaceted self-management interventions may result in little to no difference in VRQoL change score compared to active control (SMD -0.12, 95% CI -0.33 to 0.10; I2 = 48%; 4 studies, 733 participants; low-certainty evidence). The evidence from six studies by final values suggests that self-management intervention may not improve VRQoL compared to control treatment in the longer-term (6 to 24 months) (SMD -0.01, 95% CI -0.14 to 0.13; I2 = 0%; 6 studies, 864 participants; low-certainty evidence). The conclusion was unchanged, irrespective of the comparator used. We judged the certainty of evidence for both HRQoL and VRQoL as low according to GRADE criteria, downgrading one level for imprecision and one level for unexplained heterogeneity. For harms, self-management interventions may not affect the risk of adverse events (RR 1.14, 95% CI 0.78 to 1.66; I² = 0%; 2 studies, 255 participants; low-certainty evidence). Of four studies that reported adverse events, three studies observed no treatment-related adverse events. One study referred 12 (34%) participants to the general medical practitioner for depressive symptoms in the intervention group compared with seven (22%) participants in the wait list comparison group.

AUTHORS' CONCLUSIONS

In this review, we found low-certainty evidence that multifaceted self-management interventions have little or no effects on improving HRQoL and VRQoL for adults with visual impairment. Research is needed to develop more sensitive measures of quality of life and to assess the benefit of such interventions across a broader demographic, including different stages of vision impairment and people with dual-sensory impairment.

FUNDING

Cochrane Eyes and Vision US Project is supported by grant UG1EY020522, National Eye Institute, National Institutes of Health.

REGISTRATION

Protocol available via doi.org/10.1002/14651858.CD015790.

Multidimensional interventions to increase life-space mobility in older adults ranging from nursing home residents to community-dwelling: a systematic scoping review

BACKGROUND

Life-space mobility (LSM) is an important aspect of older adults' real-life mobility. Studies have shown that restricted LSM is a risk factor for many adverse outcomes such as low quality of life and mortality. Therefore, an increasing number of interventions aim to enhance LSM. However, the intervention approaches differ in terms of their type/content, duration, targeted populations, but also in terms of their outcome measures and assessment tools. Especially the latter impairs the comparability of studies with otherwise similar interventional approaches and thus also the interpretation of their results. Therefore, this systematic scoping review aims to provide an overview of the intervention components, assessment tools, and effectiveness of studies aiming to improve LSM in older adults.

METHODS

A systematic literature search was carried out in PubMed and Web of Science. We considered studies in older adults of any design that included an intervention approach and at least one outcome of LSM.

RESULTS

27 studies were included in the review. These studies analyzed healthy community-dwelling as well as frail older adults in need of care or rehabilitation and nursing home residents with a mean age between 64 and 89. The percentage of female participants ranged from 3 to 100%. The types of interventions were of the following: physical, counseling, multidimensional, miscellaneous. Multidimensional interventions consisting of physical interventions plus any of the following or a combination of counseling/education/motivation/information appear to be most effective in increasing LSM. Older adults with mobility impairments were more responsive to these multidimensional interventions compared to healthy older adults. Most of the studies used the questionnaire-based Life-Space Assessment to quantify LSM.

CONCLUSIONS

This systematic scoping review provides a comprehensive overview of a heterogenous stock of literature investigating LSM-related interventions in older adults. Future meta-analyses are needed to provide a quantitative evaluation of the effectiveness of LSM interventions and recommendations.

Designing an internet-based intervention for improving wellbeing in people with acquired vision loss: A Delphi consensus study

PURPOSE

Vision impairment (VI) may impact a person's functional ability resulting in a loss of independence, anxiety, depression, social isolation and reduced quality of life. Caregivers also experience similar problems due to the increased burden placed on them. Support to address these difficulties encountered by those with VI and their caregivers may not always be accessible. An internet-based intervention may provide more accessible support. The aim of this study was to obtain consensus regarding the content and accessibility features required to design an internet-based intervention to promote wellbeing for people with VI and their caregivers.

METHOD

A three-round Delphi review was conducted with a panel of 30 stakeholders. Three stakeholder groups were included, namely individuals with vision loss, experts in the field of vision loss and mental health and carers of individuals with vision loss. Conceptual wellbeing ideas were examined in round 1, the intervention modules and module content were proposed in round 2 and refined in round 3.

RESULTS

Consensus of 75% or more was reached to include 18 modules into the intervention. These were divided into seven sections: understanding vision loss, emotional wellbeing, functional wellbeing, social wellbeing, physical wellbeing, wellbeing for carers and maintaining wellbeing. The accessibility features deemed most important were font size, colour and contrast options, compatibility with low vision aids and layout of the intervention.

CONCLUSIONS

The Delphi process positively informed the design of an internet-based intervention for individuals with acquired VI and their caregivers. Suggestions provided by stakeholders should now be incorporated into the intervention. Future evaluation of efficacy and cost-effectiveness of such an intervention are necessary.

Chronic disease interventions for people with visual impairment: A systematic review

AIM

To identify the characteristics of chronic disease interventions for people with visual impairment (PVI) and provide suggestions for future interventions.

BACKGROUND

Chronic diseases are more common in PVI than people without visual impairment, and PVI have difficulty managing chronic diseases due to physical, social, and psychological problems associated with visual impairment. However, evidence regarding chronic disease intervention for PVI is limited.

METHODS

This review was guided by the PRISMA methodology. Data were extracted and checked, and each study was evaluated to ensure their methodological quality using appropriate tools based on the study design. Findings were described through a qualitative synthesis, and the above process was carried out by all four researchers.

RESULTS

28 studies were selected. The intervention for mental disorders was the most common with about 39.3%, followed by stroke (25.0%), diabetes (17.8%), various chronic diseases (10.7%), chronic pain (3.6%), and scoliosis (3.6%). Most of the intervention was delivered individually, and the place of intervention often depends on the preference or convenience of PVI. A wide range of intervention materials was used, from large print, audio, or braille version reading materials to technology products. Based on the results, the main areas of the outcomes were daily living function, psychological conditions, and quality of life.

CONCLUSIONS

This review identified the components of interventions for PVI and provided intervention strategies. In particular, chronic disease interventions for PVI should be planned by considering how and where appropriate interventions are provided, various available materials, and the problems to be addressed.

Low vision rehabilitation in improving the quality of life for patients with impaired vision: A systematic review and meta-analysis of 52 randomized clinical trials

BACKGROUND AIM

Low vision rehabilitation optimizes the use of residual vision after severe vision loss, but also teaches skills to improve visual functioning in daily life. These skills promote independence and active participation in society. This meta-analysis was designed to evaluate the efficacy of low vision rehabilitation in improving the quality of life (QoL) in visually impaired adults.

METHODS

We searched the Cochrane Library, PubMed, EMBASE, and Web of Science up to January 1, 2020. Randomized controlled trials (RCTs) that compared rehabilitation interventions with active or inactive controls were included. The standardized mean difference (SMD) with a 95% confidence interval (CI) was estimated to compare outcomes. Two reviewers extracted data and assessed trial quality independently. All statistical analyses were performed using the standard statistical procedures of RevMan 5.2.

RESULTS

A total of 52 RCTs with 6,239 participants were included in this meta-analysis. Compared to inactive comparators including waiting list or no care, low vision rehabilitation improved vision-related QoL, visual functioning (QoL: psychological aspect), and self-efficacy or self-esteem (QoL: psychological aspect), with pooled SMDs of -0.61 (95% CI -0.95 to -0.26; P = .0006), -1.14 (95% CI -1.69 to -0.59; P < .0001), and -0.84 (95% CI -1.47 to -0.22; P < .0001), respectively. Compared to active comparators, low vision rehabilitation improved vision-related QoL (SMD -0.26; 95% CI -0.46 to -0.06; P = .01) and activities of daily living (QoL: physical aspect) (SMD -0.39; 95% CI -0.67 to -0.12 P < .0001). However, no significant difference in health-related QoL and adaptation to vision loss (QoL: psychological aspect) was found between low vision rehabilitation and inactive comparators.

CONCLUSIONS

This meta-analysis indicated that low vision rehabilitation interventions, particularly psychological therapies and methods of enhancing vision, may improve vision-related QoL and visual functioning in people with sight loss compared to usual care. Further studies should explore longer maintenance effects and the costs of several types of low vision rehabilitation. Studies characterizing the mechanisms of rehabilitation interventions in different settings, including low-income countries, are also required.

Visual Impairment and Mental Health: Unmet Needs and Treatment Options

Purpose

An estimated 2.2 billion people are visually impaired worldwide. Given that age-related vision loss is a primary cause of vision impairment, this number is projected to rise with increases in average lifespan. Vision loss often results in significant disability and is associated with a substantial economic burden, reduced quality-of-life, concurrent medical issues, and mental health problems. In this review, the mental health needs of people with vision impairment are examined.

Patients and methods

A review of recent literature on mental health outcomes and current treatments in people with visual impairment was conducted.

Results

Considerable data indicate that rates of depression and anxiety are elevated among people with visual impairments. Moreover, individuals of lower socioeconomic status may be at increased risk for vision impairment and subsequent mental health problems. Existing psychosocial interventions for improving mental health in people with visual impairment show some promise, but are limited by low adherence and lack generalizability.

Conclusion

In order to improve outcomes, a better understanding of the mechanisms linking visual impairment and poor mental health is needed. It will also be essential to develop more effective interventions and expand access to services to improve the detection and treatment of mental health problems in this population.

Visual Impairment, Eye Disease, and the 3-year Incidence of Depressive Symptoms: The Canadian Longitudinal Study on Aging

PURPOSE

Our goal was to explore the longitudinal association between vision-related variables and incident depressive symptoms in a community-dwelling sample of older adults and to examine whether sex, education, or hearing loss act as effect modifiers.

METHODS

A 3-year prospective cohort study was performed using data from the Canadian Longitudinal Study on Aging consisting of 30,097 individuals aged 45-85 years. Visual acuity was evaluated with habitual distance correction using an illuminated Early Treatment of Diabetic Retinopathy Study chart. Visual impairment was defined as binocular presenting visual acuity worse than 20/40. Incident depressive symptoms was defined using a cut-off score of 10 or greater on the Center for Epidemiologic Studies Depression scale. Participants were asked if they had ever had a physician diagnosis of age-related macular degeneration (AMD), glaucoma, or cataract. Multivariable Poisson regression was used.

RESULTS

Of 22,558 participants without depressive symptoms at baseline, 7.7% developed depressive symptoms within 3 years. Cataract was associated with incident depressive symptoms (relative risk = 1.20, 95% confidence interval 1.05, 1.37) after adjusting for age, sex, income, education, partner status, smoking, level of comorbidity, hearing loss, and province. Visual impairment, AMD, and glaucoma were not associated with incident depressive symptoms. No effect modification was detected.

CONCLUSIONS

Our longitudinal data confirm that the risk of depressive symptoms is higher in those who report ever having a cataract. Further research should confirm this and interventions should be considered.

WITHDRAWN:The efficacy of low vision rehabilitation in improving the quality of life for patients with impaired vision: a systematic review and meta-analysis of 46 randomized clinical trials

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause.. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Facilitators and barriers to participation in mental well-being programs by older Australians with vision impairment: community and stakeholder perspectives

OBJECTIVE

Older adults with vision impairment experience high rates of mental health problems, but very few access psychological support. We investigated community and stakeholder perspectives of the barriers and facilitators to participation in mental well-being programs for older adults with vision impairment.

METHODS

Adults aged ≥ 50 years with vision impairment (community) were recruited from the client database, and low vision rehabilitation (LVR) professionals (stakeholders) from staff of a LVR provider. Participants completed one-on-one semi-structured interviews, which were designed and analyzed using behavior change theory.

RESULTS

Twenty-nine participants were interviewed; 16 community members and 13 stakeholders. Both groups cited mental health problems as a major concern, with many stakeholders reporting the grief and distress associated with vision loss experienced by their clients as having a negative impact on their mental and physical health. Major barriers to participation in mental well-being programs included a lack of awareness and difficulties accessing such programs, with stakeholders adding that their clients' lack of insight into their own mental health problems may reduce motivation to participate. Facilitators to participation in programs included the appeal of social interaction and inspirational speakers. An appropriate intervention could overcome these barriers, or enhance participation through education, persuasion, incentivisation, modeling, environmental restructuring, training, and enablement.

CONCLUSIONS

While barriers were discussed more than facilitators to participation, there was general support for mental well-being programs. This study provides guidance from stakeholders for the development of mental well-being programs to address mental health problems in the growing number of older adults with vision impairment.

Low vision rehabilitation for better quality of life in visually impaired adults

BACKGROUND

Low vision rehabilitation aims to optimise the use of residual vision after severe vision loss, but also aims to teach skills in order to improve visual functioning in daily life. Other aims include helping people to adapt to permanent vision loss and improving psychosocial functioning. These skills promote independence and active participation in society. Low vision rehabilitation should ultimately improve quality of life (QOL) for people who have visual impairment.

OBJECTIVES

To assess the effectiveness of low vision rehabilitation interventions on health-related QOL (HRQOL), vision-related QOL (VRQOL) or visual functioning and other closely related patient-reported outcomes in visually impaired adults.

SEARCH METHODS

We searched relevant electronic databases and trials registers up to 18 September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating HRQOL, VRQOL and related outcomes of adults, with an irreversible visual impairment (World Health Organization criteria). We included studies that compared rehabilitation interventions with active or inactive control.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 44 studies (73 reports) conducted in North America, Australia, Europe and Asia. Considering the clinical diversity of low vision rehabilitation interventions, the studies were categorised into four groups of related intervention types (and by comparator): (1) psychological therapies and/or group programmes, (2) methods of enhancing vision, (3) multidisciplinary rehabilitation programmes, (4) other programmes. Comparators were no care or waiting list as an inactive control group, usual care or other active control group. Participants included in the reported studies were mainly older adults with visual impairment or blindness, often as a result of age-related macular degeneration (AMD). Study settings were often hospitals or low vision rehabilitation services. Effects were measured at the short-term (six months or less) in most studies. Not all studies reported on funding, but those who did were supported by public or non-profit funders (N = 31), except for two studies. Compared to inactive comparators, we found very low-certainty evidence of no beneficial effects on HRQOL that was imprecisely estimated for psychological therapies and/or group programmes (SMD 0.26, 95% CI -0.28 to 0.80; participants = 183; studies = 1) and an imprecise estimate suggesting little or no effect of multidisciplinary rehabilitation programmes (SMD -0.08, 95% CI -0.37 to 0.21; participants = 183; studies = 2; I2 = 0%); no data were available for methods of enhancing vision or other programmes. Regarding VRQOL, we found low- or very low-certainty evidence of imprecisely estimated benefit with psychological therapies and/or group programmes (SMD -0.23, 95% CI -0.53 to 0.08; studies = 2; I2 = 24%) and methods of enhancing vision (SMD -0.19, 95% CI -0.54 to 0.15; participants = 262; studies = 5; I2 = 34%). Two studies using multidisciplinary rehabilitation programmes showed beneficial but inconsistent results, of which one study, which was at low risk of bias and used intensive rehabilitation, recorded a very large and significant effect (SMD: -1.64, 95% CI -2.05 to -1.24), and the other a small and uncertain effect (SMD -0.42, 95%: -0.90 to 0.07). Compared to active comparators, we found very low-certainty evidence of small or no beneficial effects on HRQOL that were imprecisely estimated with psychological therapies and/or group programmes including no difference (SMD -0.09, 95% CI -0.39 to 0.20; participants = 600; studies = 4; I2 = 67%). We also found very low-certainty evidence of small or no beneficial effects with methods of enhancing vision, that were imprecisely estimated (SMD -0.09, 95% CI -0.28 to 0.09; participants = 443; studies = 2; I2 = 0%) and multidisciplinary rehabilitation programmes (SMD -0.10, 95% CI -0.31 to 0.12; participants = 375; studies = 2; I2 = 0%). Concerning VRQOL, low-certainty evidence of small or no beneficial effects that were imprecisely estimated, was found with psychological therapies and/or group programmes (SMD -0.11, 95% CI -0.24 to 0.01; participants = 1245; studies = 7; I2 = 19%) and moderate-certainty evidence of small effects with methods of enhancing vision (SMD -0.24, 95% CI -0.40 to -0.08; participants = 660; studies = 7; I2 = 16%). No additional benefit was found with multidisciplinary rehabilitation programmes (SMD 0.01, 95% CI -0.18 to 0.20; participants = 464; studies = 3; I2 = 0%; low-certainty evidence). Among secondary outcomes, very low-certainty evidence of a significant and large, but imprecisely estimated benefit on self-efficacy or self-esteem was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -0.85, 95% CI -1.48 to -0.22; participants = 456; studies = 5; I2 = 91%). In addition, very low-certainty evidence of a significant and large estimated benefit on depression was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -1.23, 95% CI -2.18 to -0.28; participants = 456; studies = 5; I2 = 94%), and moderate-certainty evidence of a small benefit versus usual care (SMD -0.14, 95% CI -0.25 to -0.04; participants = 1334; studies = 9; I2 = 0%). ln the few studies in which (serious) adverse events were reported, these seemed unrelated to low vision rehabilitation.

AUTHORS' CONCLUSIONS

In this Cochrane Review, no evidence of benefit was found of diverse types of low vision rehabilitation interventions on HRQOL. We found low- and moderate-certainty evidence, respectively, of a small benefit on VRQOL in studies comparing psychological therapies or methods for enhancing vision with active comparators. The type of rehabilitation varied among studies, even within intervention groups, but benefits were detected even if compared to active control groups. Studies were conducted on adults with visual impairment mainly of older age, living in high-income countries and often having AMD. Most of the included studies on low vision rehabilitation had a short follow-up, Despite these limitations, the consistent direction of the effects in this review towards benefit justifies further research activities of better methodological quality including longer maintenance effects and costs of several types of low vision rehabilitation. Research on the working mechanisms of components of rehabilitation interventions in different settings, including low-income countries, is also needed.

Psychological and Psychosocial Interventions for Depression and Anxiety in Patients With Age-Related Macular Degeneration: A Systematic Review

OBJECTIVE

To review the current literature on psychosocial and psychological interventions to prevent and treat depression and anxiety in patients with age-related macular degeneration (AMD).

METHODS

The authors conducted a systematic review of literature evaluating psychosocial and psychological interventions for depression and anxiety in patients with AMD. Primary searches of PubMed, Cochrane library, EMBASE, Global Health, Web of Science, EBSCO, and Science Direct were conducted to include all articles published up to April 21, 2018.

RESULTS

Of a total of 398 citations retrieved, the authors selected 12 eligible studies published between 2002 and 2016. The authors found nine randomized controlled trials (RCT), and three non-randomized intervention (NRI) studies. RCT studies suggested that interventions using group self-management techniques and individual behavioral activation plus low vision rehabilitation can be effective to treat and prevent depression in patients with AMD, and one study suggested that a stepped-care intervention using cognitive-behavioral techniques can be effective to manage anxiety and depression over time. NRI studies highlighted a positive effect of self-help and emotion-focused interventions to reduce depression.

CONCLUSION

Clinical practice with patients with AMD can rely on some tailored cognitive-behavioral therapeutic protocols to improve patients' mental health, but further clinical trials will generate the necessary evidence-based knowledge to improve those therapeutic techniques and offer additional tailored interventions for patients with AMD.