- Email: [email protected]
Frequency of Ophthalmic Assessments among Elderly Whites and African Americans with Eye Disease and Impact on Visual Function
Frequency of Ophthalmic Assessments among Elderly Whites and African Americans with Eye Disease and Impact on Visual Function HOSAM K. KAMEL, MD; SAMERAH GURO-RAZUMAN, MD; MUSARAT SHAREEFF, MD
ABSTRACT: Objectives: To study the difference in patterns of utilization of eye-care services among white and African American senior citizens with eye disease and its impact on visual function. Methods: This study involved cross-sectional assessments of visual function using the Activities of Daily Vision Scale (ADVS), as well as retrospective self-recall of history of eye disease and frequency of ophthalmic assessments. Participants included 99 consecutive elderly patients with history of eye disease who were attending the outpatient medical clinics at Nassau University Medical Center, a community teaching hospital in Long Island, New York. Results: White Americans constituted 52% of the study sample and African Americans constituted the remaining 48%. African American subjects were less likely than whites to report visiting an eye specialist over the previous 5 years
(69% versus 88%, P ⬍ 0.05). African American subjects who reported undergoing ophthalmic assessments over the past 5 years showed a trend of having higher ADVS scores (indicating better visual function) compared with those who did not report such history (86 ⫾ 12 versus 79 ⫾ 15, P ⫽ 0.098). On the other hand, reporting such history had no apparent relation to the ADVS scores in whites. Conclusions: African American elderly ambulatory medical patients with eye disease were less likely than their white counterparts to report use of eye-care services. The use of eye-care services in African American but not white subjects was linked to better visual function as assessed by the ADVS. KEY INDEXING TERMS: Elderly; Vision; Assessment; African Americans; White Americans. [Am J Med Sci 2001;322(2):71–74.]
A
impairment in older persons are age-related macular degeneration, glaucoma, cataract, and diabetic retinopathy.13,14 Early detection and prompt treatment of many age-related eye diseases can prevent disability from these conditions.15 Unreported or undiagnosed visual impairment is common among older persons and is associated with considerable morbidity.16 Visual problems in older persons may go unreported for several reasons. Older adults may perceive visual changes as an expected consequence of aging and may believe nothing can be done about it.17 They may also fail to recognize their visual loss18 or may fear the costs and surgery.19 In addition, the presence of another handicap may dominate the perception of difficulties.20 The American Academy of Ophthalmology has recommended that all persons over the age of 40 years receive a complete screening eye examination by an eye specialist every 2 to 5 years and more frequently if the condition warrants.21 There are no data available to support a specific interval or content for the visual examination. There are few studies available that investigated the use of eye-care services by older adults in the United States.22–26 Data from these studies demonstrate a
ge-related eye diseases and associated visual impairment are important causes of disability among older adults in the United States.1,2 Studies have shown that 13% of Americans over the age of 65 have some form of visual impairment, and 8% have severe impairment, defined as inability to read a newspaper or blindness in both eyes.3 The prevalence of visual impairment increases to 27% among persons older than 85 years.4 Visual impairment is associated with considerable morbidity among older adults. It has been linked to increased risk for falls, hip fractures, physical disability, depression, and increased mortality.5–11 The health care costs attributable to eye disease and related visual impairment is estimated at about $22 billion per year in the United States.12The 4 most common causes of visual
From the Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, Missouri (HKK); Division of Nephrology, Nassau University Medical Center, East Meadow, New York (SG-R); Department of Neurology, Long Island Jewish Medical Center, New Hyde Park, New York (MS). Submitted January 25, 2001; accepted April 27, 2001. Correspondence: Hosam K. Kamel, M.D., FACP, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104 (E-mail: [email protected]). THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
71
Ophthalmic Assessments among Older Americans
Table 1. Population Characteristics Total n ⫽ 99 Sex Male Female Ocular disease RE Cataract Glaucoma DR MD Age (years) Mean (⫾ SD)
Whites n ⫽ 51
(52%)
Blacks n ⫽ 48
(48%)
25 74
(25%) (75%)
12 39
(24%) (76%)
13 35
(27%) (73%)
65 57 20 12 4
(66%) (58%) (20%) (12%) (4%)
40 25 5 4 3
(78%) (49%) (10%) (8%) (6%)
25 32 15 8 1
(52%) (67%) (31%) (17%) (2%)
75 (⫾ 7)
75 (⫾ 7)
74 (⫾ 8)
RE, refractive errors, DR, diabetic retinopathy, MD, macular degeneration.
low rate of utilization of eye-care services by older persons. There are no data available on the effect of using eye-care services on visual outcomes in older adults. Such data are important to estimate the magnitude of the problem and to decide about the need for action. This study investigates the frequency of using eye-care services among white and African American elderly medical outpatients with eye disease, and its impact on visual function. Methods Study Design and Subjects This is a cross-sectional study of a sample of 99 consecutive elderly medical outpatients with 1 or more of 5 ocular diseases: refractive errors (n ⫽ 65), cataract (n ⫽ 56), glaucoma (n ⫽ 20), diabetic retinopathy (n ⫽ 12), and/or macular degeneration (n ⫽ 4). Mean age of subjects was 75 ⫾ 7 years (range, 65–95 years). These subjects (51 whites and 48 African Americans) were consecutive patients with eye disease who were attending the medical outpatient clinics at Nassau University Medical Center, a major teaching affiliate of the State University of New York at Stony Brook. All subjects were asked, “Have you visited an eye care professional (an ophthalmologist or an optometrist) over the past 5 years?” Data were also available regarding age, sex, race, and self-report of eye disease. Visual function assessments were conducted using the Activities of Daily Vision Scale (ADVS).27 The ADVS assesses 20 visual activities categorized in 5 subscales (distance vision, near vision, glare disability, night driving, and daytime driving). Scores may range from 0 (inability to perform the activity because of visual difficulty) to 100 (no visual difficulty). Patients who were unable to complete the ADVS because of cognitive impairment were not included.
reported visiting an eye specialist over the past 5 years, only 69% of African American subjects reported such a history (P ⬍ 0.05). African American subjects who said they visited an eye specialist over the past 5 years scored higher on the ADVS (indicating better visual function) compared with their counterparts who did not visit an eye specialist (86 ⫾ 12 versus 79 ⫾ 15 points, P ⫽ 0.098). On the other hand, white subjects who reported a similar history scored slightly less than their counterparts who did not visit an eye specialist (85 ⫾ 16 versus 92 ⫾ 9, P ⫽ 0.4). Discussion The American Academy of Opthalmology21 recommends that those over 40 years old receive a complete screening examination every 2 to 5 years. Diabetics, however, need a yearly eye examination by a specialist.28 There are no data that support a specific content for the visual examination and, for the most part, the recommendation are based on expert opinion (Table 2). There are few data available on the utilization of eye-care services among older adults in general, and in senior citizens with eye disease in particular. Using the 1986 and 1987 Medicare Database, Javitt et al22 showed that increasing age, white race, and mean income ⬎$15,000 were associated with increased likelihood of having cataract surgery. Sastry et al,23 using data from the 1989 National Ambulatory Medical Care
Statistical Analysis Results were reported as mean (⫾ SD) unless specified otherwise. General descriptive statistics were used to define groups. Chi-square tests were used to compare dichotomous data. The 2-sample t test was used to compare groups’ means. Significance was defined as P ⬍ 0.05. Statistical analysis was performed using the statistical package STATISTICA for Windows (Statsoft Inc., Tulsa, OK).
Results The population characteristics for all subjects are displayed in Table 1. Whereas 88% of white subjects 72
Table 2. Elements of a Complete Ophthalmologic Examination as Recommended by the American Academy of Ophthalmology21 Visual acuity testing and refraction External examination (including motility and alignment) Intraocular pressure measurement Examination of the pupils Slit-lamp examination Dilated ophthalmoscopy Confrontational ⫹/⫺ formal field testing if needed
August 2001 Volume 322 Number 2
Kamel, Guro-Razuman, and Shareeff
Table 3. Eye Care Usage Pattern in Whites and African Americans and Impact on Visual Function Visited an Eye Specialist
All subjects (n ⫽ 99) Whites (n ⫽ 51) Blacks (n ⫽ 48)
Did Not Visit an Eye Specialist
n (%)
ADVS (⫾ SD)
n (%)
ADVS (⫾ SD)
73 (74%) 45 (88%) 33 (69%)
86 (⫾ 14) 85 (⫾ 16) 86 (⫾ 12)
26 (26%) 6 (12%) 15 (31%)
83 (⫾ 14) 92 (⫾ 9) 79 (⫾ 15)
Survey, reported that 90% of ophthalmology office visits were made by white patients and 5% were made by blacks. Ellwein et al24 studied claims for eye-care services within Medicare Part B and reported a low utilization rate of eye-care services by older adults. Orr et al26 conducted a populationbased survey of 2520 persons aged 62 to 84 and reported that blacks were significantly less likely to visit an eye care provider than whites. They also found that self-report of eye problems, diabetes, more education, and being a current driver were predictive of seeing an eye specialist. No studies investigated the effect of the pattern of use of eyecare services on visual outcomes in the general population or in those with established eye disease. This study investigated the frequency of using eye-care services among older white and African American medical outpatients with eye disease and its impact on visual function as assessed by the ADVS. In this study, we did not differentiate if the eye care service was provided by an ophthalmologist or by an optometrist because of the known uncertainty in reporting by the public.29 Results from this study indicate that African American elderly persons with eye disease were less likely than their white counterparts to report using eye-care services (69 versus 88%, P ⬍ 0.05). Another important finding was that older African Americans with eye disease who used eye-care services were likely to have better visual function than those who did not use such services (Table 3). This finding may be explained by the increased prevalence of cataract (67 versus 49%, P ⫽ 0.07) and glaucoma (31 versus 10%, P ⬍ 0.05) among African American subjects compared with whites. The Baltimore Eye Survey30 showed that unoperated cataract and primary-open angle glaucoma were frequent causes of blindness among African Americans, accounting for 27 and 19% of all cases of blindness, respectively. Blindness caused by cataract or glaucoma is preventable if these conditions are detected early and managed promptly. On the other hand, white senior citizens with eye disease who reported visiting an eye-care specialist scored slightly lower on the ADVS than those who did not (Table 3). This may be because of the increased frequency of macular degeneration, a progressive and untreatable eye disease, in whites THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
P 0.4 0.4 0.098
compared with African Americans (6 versus 2%, P ⫽ 0.3). One limitation of this study is that information about the presence of ocular disease and visiting an eye specialist were collected retrospectively and may have been affected by recall bias. Another limitation is that subjects included in this study were patients attending medical clinics at a county hospital. This patient population generally has less medical insurance, less education, and lower income than patients attending private hospitals. In addition, 1 study22 reported regional variations in the utilization of cataract services. Both these factors may limit the generalization of our findings. The results, however, are significant and highlight the need to develop strategies to help more older African Americans use eye-care services. These strategies should focus on the identification and removal of barriers to the access of eye-care services by African Americans, as well as on developing educational programs aimed at promoting the perception of eye care needs among this group at high risk for visual problems. References 1. West SK, Munoz B, Rubin GS, et al. Function and visual impairment in a population-based study of older adults: the SEE project, Salisbury Eye Evaluation. Invest Ophthalmol Vis Sci 1997;38:72– 82. 2. Salive ME, Guralnik J, Glynn RJ, et al. Association of visual impairment with mobility and physical function. J Am Geriatr Soc 1994;42:287–92. 3. Nelson KA. Visual impairment among elderly Americans: statistics in transition. J Vis Impair Blind 1987;81:331– 4. 4. Havlik RJ. Aging in the eighties: impaired senses for sound and light in persons age 65 and over. Preliminary data from the supplement on aging to the National Health Interview Survey: United States. January-June 1984. Advance data from Vital and Health Statistics. No. 125. Publication no DHHS (PHS) 86-1250. Hyattsville (MD): National Center for Health Statistics; 1986. 5. Nevitt MC, Cummings SR, Kidd S, et al. Risk factors for recurrent nonsyncopal falls: A prospective study. JAMA 1989; 261:2663– 8. 6. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on a number of chronic disabilities. Am J Med 1986;80:429 –34. 7. Jette AM, Branch LG. Impairment and disability in the aged. J Chronic Dis 1985;38:59 – 65.
73
Ophthalmic Assessments among Older Americans
8. Rovner BW, Zisselman PM, Shmuely-Dulitzki Y. Depression and disability in older people with impaired vision: A follow-up study. J Am Geriatr Soc 1996;44:181– 4. 9. Mor V, Murphy J, Masterson-Allen S, et al. Risk of functional decline among well elders. J Clin Epidemiol 1989; 42:875–904. 10. Inouye SK, Wagner DR, Acampora D, et al. A predictive index for functional decline in hospitalized elderly medical patients. J Gen Intern Med 1993;8:645–52. 11. Thompson JR, Gibson JM, Jagger C. The association between visual impairment and mortality in elderly people. Age Ageing 1989;18:83– 8. 12. Kalina RE. Seeing into the future: vision and aging. West J Med 1997;167:253–257. 13. Klaver CC, Wolfs RC, Vingerling JR, et al. Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Arch Ophthalmol 1998;116:653– 8. 14. Hyman L. Epidemiology of eye disease in the elderly. Eye 1987;1:330 – 41. 15. Das A. Prevention of visual loss in older adults. Clin Geriatr Med 1999;15:131– 44. 16. Smeeth L. Assessing the likely effectiveness of screening older people for impaired vision in primary care. Fam Pract 1998;15:S24 –9. 17. Landes R, Popay J. ‘My sight is poor but I’m getting on now’: the health and social care needs of older people with visual problems. Health Social Care 1993;1:325–35. 18. Long Ca, Holder R, Mulkerrin E, et al. Opportunistic screening of visual acuity of elderly patients attending outpatient clinics. Age Ageing 1991;20:392–395. 19. Reinstein DZ, Sorward NL, Wormald RP, et al. ‘Correctable undetected visual acuity deficit’ in patients aged 65 and
74
20.
21. 22.
23. 24.
25.
26.
27.
28.
29.
30.
over attending an accident and emergency department. Br J Opthalmol 1993;77:293– 6. Cullinan TR. The epidemiology of visual disability. Studies of visually disabled people in the community. Health Services Research Unit report number 28. Canterbury (UK): University of Kent; 1977. Trobe JD. The physician’s guide to eye care. San Francisco (CA): American Academy of Ophthalmology; 1993. Javitt JC, Kendic M, Tielsch JM, et al. Geographical variation in utilization of cataract surgery. Med Care 1995; 33:90 –105. Sastry SM, Chiang YP, Javitt JC. Practice patterns of the office-based ophthalmologist. Ophthalmic Surg 1994;25:76 – 81. Ellwein LB, Friedlin V, McBean AM, et al. Use of eye care service among the 1991 Medicare population. Ophthalmology 1996;103:1732– 43. Wang F, Ford D, Tielsch JM, et al. Undetected eye disease in a primary care clinic population. Arch Intern Med 1994; 154:1821– 8. Orr P, Barron Y, Schein O, et al. Eye care utilization by older Americans. The SEE Project. Ophthalmology 1999;106: 904 –909. Mangione CM, Phillips RS, Seddon JM, et al. Development of the “Activities of Daily Vision Scale.” A measure of visual functional status. Med Care 1992;30:1111–26. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2000; 23:S32– 42. Wilson MR, Lee DA, Bourque L. Does the public understand the differences between ophthalmologist and optometrist. Ophthalmol Epidemiol 1994;1:121–9. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Eng J Med 1991;325:1412–7.
August 2001 Volume 322 Number 2
ABSTRACT: Objectives: To study the difference in patterns of utilization of eye-care services among white and African American senior citizens with eye disease and its impact on visual function. Methods: This study involved cross-sectional assessments of visual function using the Activities of Daily Vision Scale (ADVS), as well as retrospective self-recall of history of eye disease and frequency of ophthalmic assessments. Participants included 99 consecutive elderly patients with history of eye disease who were attending the outpatient medical clinics at Nassau University Medical Center, a community teaching hospital in Long Island, New York. Results: White Americans constituted 52% of the study sample and African Americans constituted the remaining 48%. African American subjects were less likely than whites to report visiting an eye specialist over the previous 5 years
(69% versus 88%, P ⬍ 0.05). African American subjects who reported undergoing ophthalmic assessments over the past 5 years showed a trend of having higher ADVS scores (indicating better visual function) compared with those who did not report such history (86 ⫾ 12 versus 79 ⫾ 15, P ⫽ 0.098). On the other hand, reporting such history had no apparent relation to the ADVS scores in whites. Conclusions: African American elderly ambulatory medical patients with eye disease were less likely than their white counterparts to report use of eye-care services. The use of eye-care services in African American but not white subjects was linked to better visual function as assessed by the ADVS. KEY INDEXING TERMS: Elderly; Vision; Assessment; African Americans; White Americans. [Am J Med Sci 2001;322(2):71–74.]
A
impairment in older persons are age-related macular degeneration, glaucoma, cataract, and diabetic retinopathy.13,14 Early detection and prompt treatment of many age-related eye diseases can prevent disability from these conditions.15 Unreported or undiagnosed visual impairment is common among older persons and is associated with considerable morbidity.16 Visual problems in older persons may go unreported for several reasons. Older adults may perceive visual changes as an expected consequence of aging and may believe nothing can be done about it.17 They may also fail to recognize their visual loss18 or may fear the costs and surgery.19 In addition, the presence of another handicap may dominate the perception of difficulties.20 The American Academy of Ophthalmology has recommended that all persons over the age of 40 years receive a complete screening eye examination by an eye specialist every 2 to 5 years and more frequently if the condition warrants.21 There are no data available to support a specific interval or content for the visual examination. There are few studies available that investigated the use of eye-care services by older adults in the United States.22–26 Data from these studies demonstrate a
ge-related eye diseases and associated visual impairment are important causes of disability among older adults in the United States.1,2 Studies have shown that 13% of Americans over the age of 65 have some form of visual impairment, and 8% have severe impairment, defined as inability to read a newspaper or blindness in both eyes.3 The prevalence of visual impairment increases to 27% among persons older than 85 years.4 Visual impairment is associated with considerable morbidity among older adults. It has been linked to increased risk for falls, hip fractures, physical disability, depression, and increased mortality.5–11 The health care costs attributable to eye disease and related visual impairment is estimated at about $22 billion per year in the United States.12The 4 most common causes of visual
From the Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, Missouri (HKK); Division of Nephrology, Nassau University Medical Center, East Meadow, New York (SG-R); Department of Neurology, Long Island Jewish Medical Center, New Hyde Park, New York (MS). Submitted January 25, 2001; accepted April 27, 2001. Correspondence: Hosam K. Kamel, M.D., FACP, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104 (E-mail: [email protected]). THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
71
Ophthalmic Assessments among Older Americans
Table 1. Population Characteristics Total n ⫽ 99 Sex Male Female Ocular disease RE Cataract Glaucoma DR MD Age (years) Mean (⫾ SD)
Whites n ⫽ 51
(52%)
Blacks n ⫽ 48
(48%)
25 74
(25%) (75%)
12 39
(24%) (76%)
13 35
(27%) (73%)
65 57 20 12 4
(66%) (58%) (20%) (12%) (4%)
40 25 5 4 3
(78%) (49%) (10%) (8%) (6%)
25 32 15 8 1
(52%) (67%) (31%) (17%) (2%)
75 (⫾ 7)
75 (⫾ 7)
74 (⫾ 8)
RE, refractive errors, DR, diabetic retinopathy, MD, macular degeneration.
low rate of utilization of eye-care services by older persons. There are no data available on the effect of using eye-care services on visual outcomes in older adults. Such data are important to estimate the magnitude of the problem and to decide about the need for action. This study investigates the frequency of using eye-care services among white and African American elderly medical outpatients with eye disease, and its impact on visual function. Methods Study Design and Subjects This is a cross-sectional study of a sample of 99 consecutive elderly medical outpatients with 1 or more of 5 ocular diseases: refractive errors (n ⫽ 65), cataract (n ⫽ 56), glaucoma (n ⫽ 20), diabetic retinopathy (n ⫽ 12), and/or macular degeneration (n ⫽ 4). Mean age of subjects was 75 ⫾ 7 years (range, 65–95 years). These subjects (51 whites and 48 African Americans) were consecutive patients with eye disease who were attending the medical outpatient clinics at Nassau University Medical Center, a major teaching affiliate of the State University of New York at Stony Brook. All subjects were asked, “Have you visited an eye care professional (an ophthalmologist or an optometrist) over the past 5 years?” Data were also available regarding age, sex, race, and self-report of eye disease. Visual function assessments were conducted using the Activities of Daily Vision Scale (ADVS).27 The ADVS assesses 20 visual activities categorized in 5 subscales (distance vision, near vision, glare disability, night driving, and daytime driving). Scores may range from 0 (inability to perform the activity because of visual difficulty) to 100 (no visual difficulty). Patients who were unable to complete the ADVS because of cognitive impairment were not included.
reported visiting an eye specialist over the past 5 years, only 69% of African American subjects reported such a history (P ⬍ 0.05). African American subjects who said they visited an eye specialist over the past 5 years scored higher on the ADVS (indicating better visual function) compared with their counterparts who did not visit an eye specialist (86 ⫾ 12 versus 79 ⫾ 15 points, P ⫽ 0.098). On the other hand, white subjects who reported a similar history scored slightly less than their counterparts who did not visit an eye specialist (85 ⫾ 16 versus 92 ⫾ 9, P ⫽ 0.4). Discussion The American Academy of Opthalmology21 recommends that those over 40 years old receive a complete screening examination every 2 to 5 years. Diabetics, however, need a yearly eye examination by a specialist.28 There are no data that support a specific content for the visual examination and, for the most part, the recommendation are based on expert opinion (Table 2). There are few data available on the utilization of eye-care services among older adults in general, and in senior citizens with eye disease in particular. Using the 1986 and 1987 Medicare Database, Javitt et al22 showed that increasing age, white race, and mean income ⬎$15,000 were associated with increased likelihood of having cataract surgery. Sastry et al,23 using data from the 1989 National Ambulatory Medical Care
Statistical Analysis Results were reported as mean (⫾ SD) unless specified otherwise. General descriptive statistics were used to define groups. Chi-square tests were used to compare dichotomous data. The 2-sample t test was used to compare groups’ means. Significance was defined as P ⬍ 0.05. Statistical analysis was performed using the statistical package STATISTICA for Windows (Statsoft Inc., Tulsa, OK).
Results The population characteristics for all subjects are displayed in Table 1. Whereas 88% of white subjects 72
Table 2. Elements of a Complete Ophthalmologic Examination as Recommended by the American Academy of Ophthalmology21 Visual acuity testing and refraction External examination (including motility and alignment) Intraocular pressure measurement Examination of the pupils Slit-lamp examination Dilated ophthalmoscopy Confrontational ⫹/⫺ formal field testing if needed
August 2001 Volume 322 Number 2
Kamel, Guro-Razuman, and Shareeff
Table 3. Eye Care Usage Pattern in Whites and African Americans and Impact on Visual Function Visited an Eye Specialist
All subjects (n ⫽ 99) Whites (n ⫽ 51) Blacks (n ⫽ 48)
Did Not Visit an Eye Specialist
n (%)
ADVS (⫾ SD)
n (%)
ADVS (⫾ SD)
73 (74%) 45 (88%) 33 (69%)
86 (⫾ 14) 85 (⫾ 16) 86 (⫾ 12)
26 (26%) 6 (12%) 15 (31%)
83 (⫾ 14) 92 (⫾ 9) 79 (⫾ 15)
Survey, reported that 90% of ophthalmology office visits were made by white patients and 5% were made by blacks. Ellwein et al24 studied claims for eye-care services within Medicare Part B and reported a low utilization rate of eye-care services by older adults. Orr et al26 conducted a populationbased survey of 2520 persons aged 62 to 84 and reported that blacks were significantly less likely to visit an eye care provider than whites. They also found that self-report of eye problems, diabetes, more education, and being a current driver were predictive of seeing an eye specialist. No studies investigated the effect of the pattern of use of eyecare services on visual outcomes in the general population or in those with established eye disease. This study investigated the frequency of using eye-care services among older white and African American medical outpatients with eye disease and its impact on visual function as assessed by the ADVS. In this study, we did not differentiate if the eye care service was provided by an ophthalmologist or by an optometrist because of the known uncertainty in reporting by the public.29 Results from this study indicate that African American elderly persons with eye disease were less likely than their white counterparts to report using eye-care services (69 versus 88%, P ⬍ 0.05). Another important finding was that older African Americans with eye disease who used eye-care services were likely to have better visual function than those who did not use such services (Table 3). This finding may be explained by the increased prevalence of cataract (67 versus 49%, P ⫽ 0.07) and glaucoma (31 versus 10%, P ⬍ 0.05) among African American subjects compared with whites. The Baltimore Eye Survey30 showed that unoperated cataract and primary-open angle glaucoma were frequent causes of blindness among African Americans, accounting for 27 and 19% of all cases of blindness, respectively. Blindness caused by cataract or glaucoma is preventable if these conditions are detected early and managed promptly. On the other hand, white senior citizens with eye disease who reported visiting an eye-care specialist scored slightly lower on the ADVS than those who did not (Table 3). This may be because of the increased frequency of macular degeneration, a progressive and untreatable eye disease, in whites THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
P 0.4 0.4 0.098
compared with African Americans (6 versus 2%, P ⫽ 0.3). One limitation of this study is that information about the presence of ocular disease and visiting an eye specialist were collected retrospectively and may have been affected by recall bias. Another limitation is that subjects included in this study were patients attending medical clinics at a county hospital. This patient population generally has less medical insurance, less education, and lower income than patients attending private hospitals. In addition, 1 study22 reported regional variations in the utilization of cataract services. Both these factors may limit the generalization of our findings. The results, however, are significant and highlight the need to develop strategies to help more older African Americans use eye-care services. These strategies should focus on the identification and removal of barriers to the access of eye-care services by African Americans, as well as on developing educational programs aimed at promoting the perception of eye care needs among this group at high risk for visual problems. References 1. West SK, Munoz B, Rubin GS, et al. Function and visual impairment in a population-based study of older adults: the SEE project, Salisbury Eye Evaluation. Invest Ophthalmol Vis Sci 1997;38:72– 82. 2. Salive ME, Guralnik J, Glynn RJ, et al. Association of visual impairment with mobility and physical function. J Am Geriatr Soc 1994;42:287–92. 3. Nelson KA. Visual impairment among elderly Americans: statistics in transition. J Vis Impair Blind 1987;81:331– 4. 4. Havlik RJ. Aging in the eighties: impaired senses for sound and light in persons age 65 and over. Preliminary data from the supplement on aging to the National Health Interview Survey: United States. January-June 1984. Advance data from Vital and Health Statistics. No. 125. Publication no DHHS (PHS) 86-1250. Hyattsville (MD): National Center for Health Statistics; 1986. 5. Nevitt MC, Cummings SR, Kidd S, et al. Risk factors for recurrent nonsyncopal falls: A prospective study. JAMA 1989; 261:2663– 8. 6. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on a number of chronic disabilities. Am J Med 1986;80:429 –34. 7. Jette AM, Branch LG. Impairment and disability in the aged. J Chronic Dis 1985;38:59 – 65.
73
Ophthalmic Assessments among Older Americans
8. Rovner BW, Zisselman PM, Shmuely-Dulitzki Y. Depression and disability in older people with impaired vision: A follow-up study. J Am Geriatr Soc 1996;44:181– 4. 9. Mor V, Murphy J, Masterson-Allen S, et al. Risk of functional decline among well elders. J Clin Epidemiol 1989; 42:875–904. 10. Inouye SK, Wagner DR, Acampora D, et al. A predictive index for functional decline in hospitalized elderly medical patients. J Gen Intern Med 1993;8:645–52. 11. Thompson JR, Gibson JM, Jagger C. The association between visual impairment and mortality in elderly people. Age Ageing 1989;18:83– 8. 12. Kalina RE. Seeing into the future: vision and aging. West J Med 1997;167:253–257. 13. Klaver CC, Wolfs RC, Vingerling JR, et al. Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Arch Ophthalmol 1998;116:653– 8. 14. Hyman L. Epidemiology of eye disease in the elderly. Eye 1987;1:330 – 41. 15. Das A. Prevention of visual loss in older adults. Clin Geriatr Med 1999;15:131– 44. 16. Smeeth L. Assessing the likely effectiveness of screening older people for impaired vision in primary care. Fam Pract 1998;15:S24 –9. 17. Landes R, Popay J. ‘My sight is poor but I’m getting on now’: the health and social care needs of older people with visual problems. Health Social Care 1993;1:325–35. 18. Long Ca, Holder R, Mulkerrin E, et al. Opportunistic screening of visual acuity of elderly patients attending outpatient clinics. Age Ageing 1991;20:392–395. 19. Reinstein DZ, Sorward NL, Wormald RP, et al. ‘Correctable undetected visual acuity deficit’ in patients aged 65 and
74
20.
21. 22.
23. 24.
25.
26.
27.
28.
29.
30.
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