- Email: [email protected]
Primary eye care services offered to older adults
European Geriatric Medicine 6 (2015) 241–244
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Primary eye care services offered to older adults H. Kergoat a,b,*, S.J. Leat c, C. Faucher a, S. Roy b, M.-J. Kergoat b,d,** E´cole d’optome´trie, Universite´ de Montre´al, CP 6128, succursale centre-ville, Montre´al, H3C 3J7 QC, Canada Institut universitaire de ge´riatrie de Montre´al, Montre´al, Canada c School of Optometry and Vision Science, University of Waterloo, Waterloo, Canada d Faculte´ de me´decine, Universite´ de Montre´al, Montre´al, Canada a
b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 24 July 2014 Accepted 7 November 2014 Available online 11 April 2015
Purpose: Eye care services in long-term care facilities are not optimal and should be improved. In Canada, optometrists are the major providers of primary oculovisual examinations. Our objective was to evaluate the eye care services optometrists offer to older adults, in particular to frail older adults. Materials and methods: A questionnaire regarding older adult patients 65 years of age was designed and sent to optometrists in active practice throughout Canada. Questions related to the optometrist’s personal and practice profiles, the treatment and management of older patients, and gerontology/ geriatric education. Results: The overall average response rate for the entire country was 31.3%. About a third of all patients examined by optometrists in their office are 65 years of age. Optometrists examine about 2 to 4 older frail patients weekly in their office. Many optometrists are already examining older frail patients outside the office, and a greater proportion would accept to do so if they were asked, but on an exceptional basis. The main reasons for not seeing patients outside of the office relate to the lack of adequate fees, instrumentation and structural organization. Discussion/conclusion: Optometrists examine a large proportion of older patients in their office, but only a small proportion of those are frail older adults. However, some optometrists examine older frail patients outside the office, and more would consider doing so if the working conditions and remuneration were improved. Solutions could therefore be implemented to improve accessibility to eye care services for older frail seniors in their living environment. ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Eye care services Geriatric optometry Geriatrics Older frail individuals Optometrists
1. Introduction The most recent statistics in Canada and the USA indicate that 12.9 to 16.6% of the population is 65 years of age [1–3], a prevalence that will reach 19 to 26% by the years 2030–2036 [2–4]. In Europe, data indicate that 17.4% of the population is 65 years of age, a prevalence that will reach 28% by 2020 [5]. Population aging is characterized by rising rates of multiple chronic diseases and a greater experience of functional decline [6]. Statistics indicate that most people 65 years of age live at home or in residential care facilities, while only a minority have severe enough health-related incapacities to require placement in
* Corresponding author. E´cole d’optome´trie, Universite´ de Montre´al, CP 6128, succursale centre-ville, Montre´al, H3C 3J7, QC, Canada. Tel.: +514 343 7507; fax: +514 343 2382. ** Alternative correspondent. Tel.: +514 340 3515; fax: +514 340 2832. E-mail addresses: [email protected] (H. Kergoat), [email protected] (M.-J. Kergoat).
long-term care facilities (LTCF). There are about 155,000 older Canadians living in LCTF [7], including about 34,000 in Quebec [8]. In the USA, some 1.25 million persons 65 years of age were living in nursing home in 2010 [9]. Aging is also accompanied by an increased prevalence of eye diseases. The four main causes of visual deficit and functional blindness in developed countries are more prevalent with increasing age, i.e., age-related macular degeneration, glaucoma, cataract and diabetic retinopathy [10–12]. Older individuals require regular eye examinations to adjust for changes in their refraction, evaluate their oculovisual health, treat active ocular disease and, whenever possible, alleviate a visual handicap with assistive devices. Current standards of care recommend a yearly eye examination for those 65 years of age [13–15]. Older seniors living in LTCF, in particular, should receive a regular eye examination considering that visual deficits can be 3 to 15 times more prevalent in institutional vs. community-dwelling older individuals [16]. Recent data indicate, however, that older LTCF residents do not receive eye care services on a regular basis [17].
http://dx.doi.org/10.1016/j.eurger.2014.11.011 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
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H. Kergoat et al. / European Geriatric Medicine 6 (2015) 241–244
Because primary care eye examinations in North America are offered mostly by optometrists, our objective was to determine the extent of eye care services they offer to older Canadians, with particular attention to older frail seniors, within and outside the office.
Table 1 Canadian provinces and territories with number of optometrists who were invited to take part and percentage of respondents per area. Province–territory
Number of optometrists per province or territory invited to participate
Number of respondents per province or territory
Percentage of responses per province, territory or countryb
Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon Total
542 475 130 116 46 94 1415 15 1304 143 0 0 3 4283
129 97 30 34 8 27 330 4 560 26 – – 1 1246 (93)a
23.8 20.4 23.1 29.3 17.4 28.7 23.3 26.7 42.9 18.2 – – 33.3 31.3
2. Methods 2.1. Survey A questionnaire targeting practicing optometrists was developed for this study. It contained questions related to: personal and practice profile, treatment and management of older patients, and gerontology/geriatric education. The questionnaire was pre-tested by five optometrists, reviewed and finalized. It was written in French, with back translation in English and French again to ensure accuracy of content in both official Canadian languages. This final version was put on two Survey Monkey websites, to facilitate the communication with optometrists. Those practicing in Quebec (Qc) received the French version of the questionnaire and those practicing in the rest of Canada (RoC), the English version. Automated group email reminders could then be sent easily in French or English. This study was approved by the Research Ethics Committee of the University of Montreal. 2.2. Optometrists A list of all practicing optometrists, containing their mailing and email addresses if available, was obtained from official optometric organizations. Optometrists were contacted by email if available, or by regular mail. The questionnaire was sent to 4283 optometrists (2979 RoC/1304 Qc). Optometrists contacted by mail received a printed questionnaire, a return stamped envelope, and a web link to enter the Survey Monkey questionnaire. For those contacted by email, the email contained only the web link access. The questionnaire remained open for 8 (RoC) and 9 (Qc) months (overlapping 2011–2012), and reminders were sent to maximize the response rate (RR). The web link period for filling the questionnaire was a little shorter for the RoC because it was not providing any more responses in spite of further reminders. To be included, a questionnaire had to be complete according to the respondent, i.e., by pressing ‘‘send’’ on the web or mailing in the filled questionnaire. 3. Results Results will be presented for the RoC and Qc (RoC/Qc), rather than compiled together, mainly for technical reasons linked to the Survey Monkey sites hosting the questionnaire. Table 1 lists the provinces and territories of Canada, number of practicing optometrists and respondents, and RR obtained. Altogether, 1339 optometrists completed the questionnaire, for an overall RR of 31.3%. In total, 53.7% (RoC)/67.1% (Qc) of respondents were female and the average age of optometrists was 42.3 11.8/43.7 12.0 years. The average years in practice were 16.1 12.2/19.3 12.2 years, optometrists working on average 4.3 1.0/4.0 1.0 days/week. Although all offices see patients by appointment, a good proportion also accepts patients by a drop-in system (35.9%/35.3%) and the majority (86.1%/89.4%) accept ocular emergencies. The offices are wheelchair accessible in 91.2%/87.4% of cases and adapted for older adults (eg. rails in restroom) in 67.7%/37%. Most of the time, wheelchair patients are transferred into the ophthalmic chair for their eye examination (83.9%/90.1%), but a good proportion of optometrists also examine patients in the wheelchair
a n = 93: optometrists from the RoC who did not answer the question related to their province/territory. b Best estimate possible, not taking into account those for whom the province/ territory was not available.
with regular (49.5%/31.8%) or portable (56.3%/43.6%) instrumentation when required. In a typical week, optometrists see an average of 62.6 27.3/ 49.9 19.3 patients, with 31.9% 14.8/34.0% 15.3 being 65 years of age (Table 2). Within this older population, 93.8%/86.6% of optometrists indicated examining ‘‘frail’’ patients in the office, seeing a median of 4.0/2.0 such patients per week. For this survey, frail older patients were defined as those 65 years of age who have polymorbidity, functional impairment, and who rely on others for some activities of daily living [18]. The main reason explaining why some optometrists do not see frail patients, inside or outside the office, is that they have not been contacted to do so. Among respondents, 52.1%/22.1% indicated that they have the special equipment required to perform eye examinations outside the office and 23.7%/7.3% actually see frail older patients outside of the office. They do so at a median of 1.0/2.0 days/month, seeing about 3.0/4.0 patients/month, mainly in LTCF, in assisted living facilities, at the person’s home or at the hospital. Those optometrists were approached by patients’ family consulting at the office, contacted by an institution, or by another professional to request an examination outside of the office for these individuals. Caring for older frail patients often requires interaction with other professionals. Although 31.3%/29.9% of optometrists indicated not having to do so, when a consultation is needed, it is mainly with ophthalmologists, family physicians, physicians or nurses at a LTCF and low-vision centers. While 82.6%/59.0% of optometrists interacting with other professionals do not have difficulty finding the right resource person, an ophthalmologist is most often cited as being difficult to find when a referral for older frail patients is needed.
Table 2 Average percent of patients in the various age categories seen by optometrists in a typical week. Age category (years)
Percentage of patients RoC
Percentage of patients Qc
0–6 7–18 19–64 65
8.8 6.7 16.8 7.8 42.8 14.1 31.9 14.8
7.0 4.8 15.8 7.7 43.7 13.6 34.0 15.3
H. Kergoat et al. / European Geriatric Medicine 6 (2015) 241–244
When specifically asked if they would consider seeing more older frail patients in their office, 94.3%/88.7% of optometrists answered positively. Furthermore, 41.0%/17.7% would be ready to examine them outside the office. Of the latter, 36.4%/53.6% would accept these patients only on an exceptional basis, while as many as 41.4%/30.9% would accept to do so 0.5 day/month. A minority (8.6%/9.3%) would be willing to offer up to 0.5 day/week. The main reasons given by optometrists for not wanting to see more older frail patients outside the office were that they do not have the time or specialized equipment required to examine these patients adequately, the fact that there is no additional fee or an insufficient fee to take into account the extra time required to adequately serve this population and the lack of a good structural organization to help with the management of these patients (e.g., providing a fully equipped eye examination room, providing support staff to coordinate the appointments and accompany patients). Finally, 38.3%/50.5% of optometrists felt they needed more education in gerontology/geriatrics to help them in the care of older frail patients. The two main areas cited were on the adaptation of the visual examination for these patients and cognitive disorders. However, only 11.2%/18.1% of optometrists indicated that receiving this education would encourage them to increase the number of frail older patients they examine, while another 43.6%/44.3% indicated that it might encourage them.
4. Discussion The focus of this report is to describe the extent of services optometrists offer to older seniors, particularly older frail seniors. Although the data are presented for the rest of Canada and Quebec separately, the intent is not to compare practices between them. However, some comments are provided when large discrepancies exist. The RR obtained between optometrists in the RoC (26.1%) vs. Qc (42.9%) differed substantially, (Table 1) and might be explained by two related factors. First, most optometrists practicing in Quebec were trained in their province at the E´cole d’optome´trie de l’Universite´ de Montre´al (E´OUM) while most optometrists in the rest of Canada were trained at the School of Optometry and Vision Sciences in Ontario. Second, optometrists in Quebec may have a closer relationship with their alma mater considering that a good part of the mandatory continuing education they take on a regular basis is provided at the E´OUM. Quebec optometrists may therefore have replied in greater number to a survey hosted by their School in their province. Although optometrists’ offices see patients mainly by appointment, the majority accept ocular emergencies and about a third have a dropin system. This schedule flexibility is certainly an advantage to patients and should be remembered by older individuals and those caring for them. In particular, optometrists could help older patients with ocular emergencies, thus avoiding a long wait in a hospital emergency room. The optometrist may also be able to help the person obtain a quick appointment with an ophthalmologist if required by their condition or counsel the person if a health problem is detected. However, as many as 17.4% (RoC) and 41% (Qc) of optometrists had difficulty finding another professional when a referral was necessary, indicating a possible lack of care for older frail patients. Most offices are wheelchair accessible and some are adapted for these patients. The environmental adaptations made to an office are particularly important to older patients, in view of the increased vulnerability that may come with age. Elevators, chairs with arms as well as a hard seat and backrest and rails in the bathroom are all elements that will facilitate access to the office, and help older patients once there. Older individuals consulting optometrists represent about a third of their patients although they comprise some 15% of the general population. This indicates the greater need for eye care and that services are available for, and
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used by, individuals in this age group. Our data further indicate that only a minority of older patients seen by optometrists are frail, less than the reported proportion of frail seniors in the older population [19]. This suggests that the vast majority of older patients consulting their primary eye care providers in office are those who are functionally independent in spite of advancing age. The main reason optometrists gave for not seeing more frail patients in the office is that none call for an appointment. This suggests that more information should be available to the public in general, and to the different health organizations caring for frail individuals, regarding the importance of eye care and the eye care services that are available. Optometrists also see older frail patients outside the office (23.7% RoC/7.3% Qc), and a greater proportion would be available to do so if they were asked. This is quite impressive since these data indicate that optometrists are providing services in non-traditional settings even without a supporting health network or adequate fee. This should reassure, but at the same time, challenge health care policy makers. It could effectively be argued that if special adaptations were made, such as providing a fully equipped eye examination room in LTCF, adjusting professional fees to compensate the extra time required to examine these patients, providing support staff to coordinate appointments and accompany the patients to the examination room, optometric services could be further increased for this older frail population. It is important to remember that for this quality of patients, eye care services should be offered in a familiar environment within their respective institutions, particularly if dementia is present, since going outside could increase the risk of behavioral problems and delirium [20,21]. Statistics and demographics clearly indicate that the number of older individuals will rise over the next decades and many will be affected by diseases making them more frail. Many of them, those with advanced dementia among others, will require care at the bedside. Vision is an important component of quality of life [22–24] while visual loss, on the other hand, can contribute to dependency, anxiety, depression, isolation, behavioral problems, delirium and falls [25–29]. Furthermore, ocular pathology leading to visual loss increases with older age. It is therefore important to ensure that these individuals have access to adequate eye care to optimize their vision and, whenever possible, improve their quality of life and decrease the negative effects vision loss may have on their overall health. It is interesting to highlight a few differences that were found between the rest of Canada vs. Quebec. More offices (67.7%/37.0%) in the rest of Canada have been adapted for the needs of older patients, and more frail patients (4.0/2.0) are seen in office every week. Also, more offices in the rest of Canada have the special equipment required to offer eye examinations outside of the office (52.1%/22.1%), and a greater proportion of optometrists actually offer eye care outside the office (23.7%/7.3%), would be willing to do so if asked (41.0%/17.7%), and could offer up to 0.5 day/month (41.4%/30.9%) to care for frail patients. Considering the lower RR obtained in the rest of Canada, it might be that optometrists who responded to our survey were those particularly interested in caring for older adults, including frail seniors. If that were the case, this would have biased the data in favor of optometrists outside Quebec offering more care to frail seniors, while in reality, this difference may not be as great. This could also explain why their offices seem to be better equipped with special instrumentation and better adapted physically for these patients. Also, health care being of provincial jurisdiction, there may exist inter-provincial differences in the organization of eye care services, with advantages in the rest of Canada, facilitating the provision of eye care services outside the office for frail seniors. It is interesting to see that a good proportion of optometrists would like to receive more education to help them with older frail
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patients, but that this would not necessarily increase the proportion of patients they would examine in that category. It might be that those already providing this service would like to improve their knowledge to better serve their patients, without necessarily wanting to increase their number under the current conditions of practice. The principal areas of interest for more education were on how to adapt their visual examination for these patients and cognitive disorders. These two factors may be strongly related. In Canada, the most frail older adults are often aged 75 years and affected by dementia. Dementia affects about 12% and 33% of Canadians aged 65 years and 85 years, respectively [30]. When examining older patients with more advanced dementia, it is important to adapt the examination techniques in order to maximize the response to the tests while minimizing fatigue, anxiety or distress of the person being examined. Data indicate that when these elements are considered, it is possible to provide adequate eye care to older individuals independent of their age, level of cognition or communication abilities [31]. A limitation of the data is that they were self-reported by the optometrists, to the best of their knowledge. It would have been beyond the scope of this project to ask for numbers from patient files, since these statistics may not exist. The optometrists were aware that their data would remain anonymous so there is no reason to suspect misclassification due to a tendency to give more desirable answers.
[2] [3] [4]
[5] [6]
[7] [8]
[9] [10]
[11] [12] [13] [14]
[15]
5. Conclusion In conclusion, older individuals comprise about a third of all patients examined by Canadian optometrists, including a small proportion of frail older patients. Some optometrists are already seeing older frail patients outside the office, and more would be willing to do so if asked. However, under the actual conditions of practice, most optometrists would accept these patients outside the office only on an exceptional basis. Considering that the main reasons for not seeing patients outside the office are lack of adequate fees, instrumentation and structural organization, it would be relevant for governments to explore ways by which such services could be offered with adequate compensation. This is important for meeting the needs of older seniors, considering the growing aging of the population and knowing that frail seniors do not receive optimal eye care in many regions.
[16] [17]
[18] [19]
[20]
[21]
[22]
[23]
Disclosure of interest
[24]
The authors declare that they have no conflicts of interest concerning this article.
[25]
Acknowledgements
[26] [27]
This work was supported by a grant from the Fondation Caroline-Durand [HK and MJK]. The funding source had no involvement in any aspect of the work. We thank all optometrists who helped with the pre-testing of the questionnaire as well as all those who took the time to complete it.
[28]
[29] [30]
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2011/as-sa/98-311-x/98-311-x2011001-eng.pdf (accessed February 20, 2014]. Le bilan de´mographique du Que´bec; 2013, http://www.stat.gouv.qc.ca/ statistiques/population-demographie/index.html [Accessed on May 7, 2014]. http://www.aoa.gov/Aging_Statistics [accessed June 3, 2014]. Statistics Canada. Demographic division. Population projections for Canada, provinces and territories. 2009 to 2036. Catalogue no 91-520-X; 2010, http:// www.statcan.gc.ca/pub/91-520-x/91-520-x2010001-eng.pdf [accessed February 20, 2014]. http://ec.europa.eu/health/ageing/policy/index_en.htm [accessed July 23, 2014]. The Chief Public Health Officer’s Report on the state of Public Health in Canada. Growing older - adding life to years; 2010, http://www.phac-aspc.gc.ca/ cphorsphc-respcacsp/2010/fr-rc/index-eng.php [accessed on May 3, 2014]. Statistics Canada. Residential Care Facilities 2008/2009. Catalogue no. 83-237X; 2011 [p. 50, p. 55. Accessed on February 20, 2014]. Sante´ et services sociaux Que´bec. Info-He´bergement; 2010, http://www. informa.msss.gouv.qc.ca/Details.aspx?Id=E1c4CSCy+Sg= [accessed on February 20, 2014]. U.S. Census Bureau. Census Brief: the Older Population; 2010 [Accessed June 3, 2014]. The national coalition for vision health. Foundations for a Canadian vision health strategy. Towards preventing avoidable blindness and promoting vision health; 2007, 111p. http://www.cdc.gov/visionhealth/basic_information/eye_disorders.htm [Accessed June 3, 2014]. The Eye Diseases Prevalence Research Group. Arch Ophthalmol 2004;122: 477–85. Ordre des optome´tristes du Que´bec. Guide d’exercice. http://www.ooq.org/. Accessed on April 2014. Robinson BE, Stolee P, Mairs K, Santi S, Glenny C. Review of the Canadian Association of Optometrists. Frequency of eye examinations guideline - Summary. An evidence-based approach. Can J Optom 2011;73:15–6. http://www.aoa.org/documents/optometrists/CPG-1.pdf [Accessed June 3, 2014]. Owsley C, McGwin G, Scilley K, et al. The visual status of older persons residing in nursing homes. Arch Ophthalmol 2007;125:925–30. Kergoat H, Boisjoly H, Freeman EE, Monette J, Roy S, Kergoat MJ. The perceived needs and availability of eye care services for older adults in Quebec long-term care facilities. Can Geriatr J 2014;17:108–13. Rockwood K, Minitski A. Frailty in relation to the accumulation of deficits. J Gerontol 2007;62:722–7. Santos-Eggimann B, Cue´noud P, Spagnoli J, Junod J. Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. J Gerontol 2009;64A:675–81. National institute for health care excellence. Delirium. Diagnosis, prevention and management. NICE clinical guideline 103; 2010, http://www.nice.org.uk/ CG103 [accessed on April 29, 2014]. Hottin P, Bonin C. Symptoˆmes comportementaux et psychologiques de la de´mence. In: Arcand-He´bert, editor. Pre´cis pratique de ge´riatrie. 3e Ed., Canada: Edisem, Maloine; 2007. Coleman Al, Yu F, Keeler E, Mangione CM. Treatment of uncorrected refractive error improves vision-specific quality of life. J Am Geriatr Soc 2006;54(6):883–90. Owsley C, McGwin G, Scilley K, et al. Effect of refractive error correction on health-related quality of life and depression in older nursing home residents. Arch Ophthalmol 2007;125:1471–7. Owsley C, McGwin G, Scilley K, et al. Impact of cataract surgery on healthrelated quality of life in nursing home residents. Br J Ophthalmol 2007;91:1359–63. Carabellese C, Appollonio I, Rozzini R, Bianchetti A, Frisoni GB, Frattola L, et al. Sensory impairment and quality of life in a community elderly population. J Am Geriatr Soc 1993;41:401–7. Dargent-Molina P, Favier F, Grandjean H, et al. Fall-related factors and risk of hip fracture: the EPIDOS prospective study. Lancet 1996;348:145–9. 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. Horowitz A. The relationship between vision impairment and the assessment of disruptive behaviors among nursing home residents. Gerontologist 1997;37:620–8. Harwood RH. Visual problems and falls. Age Ageing 2001;30S4:13–8. The Canadian Study of Health, Aging Working Group. Canadian Study of Health and Aging: study methods and prevalence of dementia. Can Med Assoc J 1994;150:899–913. Carcenac G, He´rard ME`, Kergoat MJ, Lajeunesse Y, Champoux N, Barsauskas A, et al. Assessment of visual function in institutionalized elderly patients. J Am Med Dir Assoc 2009;10:45–9.
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Primary eye care services offered to older adults H. Kergoat a,b,*, S.J. Leat c, C. Faucher a, S. Roy b, M.-J. Kergoat b,d,** E´cole d’optome´trie, Universite´ de Montre´al, CP 6128, succursale centre-ville, Montre´al, H3C 3J7 QC, Canada Institut universitaire de ge´riatrie de Montre´al, Montre´al, Canada c School of Optometry and Vision Science, University of Waterloo, Waterloo, Canada d Faculte´ de me´decine, Universite´ de Montre´al, Montre´al, Canada a
b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 24 July 2014 Accepted 7 November 2014 Available online 11 April 2015
Purpose: Eye care services in long-term care facilities are not optimal and should be improved. In Canada, optometrists are the major providers of primary oculovisual examinations. Our objective was to evaluate the eye care services optometrists offer to older adults, in particular to frail older adults. Materials and methods: A questionnaire regarding older adult patients 65 years of age was designed and sent to optometrists in active practice throughout Canada. Questions related to the optometrist’s personal and practice profiles, the treatment and management of older patients, and gerontology/ geriatric education. Results: The overall average response rate for the entire country was 31.3%. About a third of all patients examined by optometrists in their office are 65 years of age. Optometrists examine about 2 to 4 older frail patients weekly in their office. Many optometrists are already examining older frail patients outside the office, and a greater proportion would accept to do so if they were asked, but on an exceptional basis. The main reasons for not seeing patients outside of the office relate to the lack of adequate fees, instrumentation and structural organization. Discussion/conclusion: Optometrists examine a large proportion of older patients in their office, but only a small proportion of those are frail older adults. However, some optometrists examine older frail patients outside the office, and more would consider doing so if the working conditions and remuneration were improved. Solutions could therefore be implemented to improve accessibility to eye care services for older frail seniors in their living environment. ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Eye care services Geriatric optometry Geriatrics Older frail individuals Optometrists
1. Introduction The most recent statistics in Canada and the USA indicate that 12.9 to 16.6% of the population is 65 years of age [1–3], a prevalence that will reach 19 to 26% by the years 2030–2036 [2–4]. In Europe, data indicate that 17.4% of the population is 65 years of age, a prevalence that will reach 28% by 2020 [5]. Population aging is characterized by rising rates of multiple chronic diseases and a greater experience of functional decline [6]. Statistics indicate that most people 65 years of age live at home or in residential care facilities, while only a minority have severe enough health-related incapacities to require placement in
* Corresponding author. E´cole d’optome´trie, Universite´ de Montre´al, CP 6128, succursale centre-ville, Montre´al, H3C 3J7, QC, Canada. Tel.: +514 343 7507; fax: +514 343 2382. ** Alternative correspondent. Tel.: +514 340 3515; fax: +514 340 2832. E-mail addresses: [email protected] (H. Kergoat), [email protected] (M.-J. Kergoat).
long-term care facilities (LTCF). There are about 155,000 older Canadians living in LCTF [7], including about 34,000 in Quebec [8]. In the USA, some 1.25 million persons 65 years of age were living in nursing home in 2010 [9]. Aging is also accompanied by an increased prevalence of eye diseases. The four main causes of visual deficit and functional blindness in developed countries are more prevalent with increasing age, i.e., age-related macular degeneration, glaucoma, cataract and diabetic retinopathy [10–12]. Older individuals require regular eye examinations to adjust for changes in their refraction, evaluate their oculovisual health, treat active ocular disease and, whenever possible, alleviate a visual handicap with assistive devices. Current standards of care recommend a yearly eye examination for those 65 years of age [13–15]. Older seniors living in LTCF, in particular, should receive a regular eye examination considering that visual deficits can be 3 to 15 times more prevalent in institutional vs. community-dwelling older individuals [16]. Recent data indicate, however, that older LTCF residents do not receive eye care services on a regular basis [17].
http://dx.doi.org/10.1016/j.eurger.2014.11.011 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
242
H. Kergoat et al. / European Geriatric Medicine 6 (2015) 241–244
Because primary care eye examinations in North America are offered mostly by optometrists, our objective was to determine the extent of eye care services they offer to older Canadians, with particular attention to older frail seniors, within and outside the office.
Table 1 Canadian provinces and territories with number of optometrists who were invited to take part and percentage of respondents per area. Province–territory
Number of optometrists per province or territory invited to participate
Number of respondents per province or territory
Percentage of responses per province, territory or countryb
Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon Total
542 475 130 116 46 94 1415 15 1304 143 0 0 3 4283
129 97 30 34 8 27 330 4 560 26 – – 1 1246 (93)a
23.8 20.4 23.1 29.3 17.4 28.7 23.3 26.7 42.9 18.2 – – 33.3 31.3
2. Methods 2.1. Survey A questionnaire targeting practicing optometrists was developed for this study. It contained questions related to: personal and practice profile, treatment and management of older patients, and gerontology/geriatric education. The questionnaire was pre-tested by five optometrists, reviewed and finalized. It was written in French, with back translation in English and French again to ensure accuracy of content in both official Canadian languages. This final version was put on two Survey Monkey websites, to facilitate the communication with optometrists. Those practicing in Quebec (Qc) received the French version of the questionnaire and those practicing in the rest of Canada (RoC), the English version. Automated group email reminders could then be sent easily in French or English. This study was approved by the Research Ethics Committee of the University of Montreal. 2.2. Optometrists A list of all practicing optometrists, containing their mailing and email addresses if available, was obtained from official optometric organizations. Optometrists were contacted by email if available, or by regular mail. The questionnaire was sent to 4283 optometrists (2979 RoC/1304 Qc). Optometrists contacted by mail received a printed questionnaire, a return stamped envelope, and a web link to enter the Survey Monkey questionnaire. For those contacted by email, the email contained only the web link access. The questionnaire remained open for 8 (RoC) and 9 (Qc) months (overlapping 2011–2012), and reminders were sent to maximize the response rate (RR). The web link period for filling the questionnaire was a little shorter for the RoC because it was not providing any more responses in spite of further reminders. To be included, a questionnaire had to be complete according to the respondent, i.e., by pressing ‘‘send’’ on the web or mailing in the filled questionnaire. 3. Results Results will be presented for the RoC and Qc (RoC/Qc), rather than compiled together, mainly for technical reasons linked to the Survey Monkey sites hosting the questionnaire. Table 1 lists the provinces and territories of Canada, number of practicing optometrists and respondents, and RR obtained. Altogether, 1339 optometrists completed the questionnaire, for an overall RR of 31.3%. In total, 53.7% (RoC)/67.1% (Qc) of respondents were female and the average age of optometrists was 42.3 11.8/43.7 12.0 years. The average years in practice were 16.1 12.2/19.3 12.2 years, optometrists working on average 4.3 1.0/4.0 1.0 days/week. Although all offices see patients by appointment, a good proportion also accepts patients by a drop-in system (35.9%/35.3%) and the majority (86.1%/89.4%) accept ocular emergencies. The offices are wheelchair accessible in 91.2%/87.4% of cases and adapted for older adults (eg. rails in restroom) in 67.7%/37%. Most of the time, wheelchair patients are transferred into the ophthalmic chair for their eye examination (83.9%/90.1%), but a good proportion of optometrists also examine patients in the wheelchair
a n = 93: optometrists from the RoC who did not answer the question related to their province/territory. b Best estimate possible, not taking into account those for whom the province/ territory was not available.
with regular (49.5%/31.8%) or portable (56.3%/43.6%) instrumentation when required. In a typical week, optometrists see an average of 62.6 27.3/ 49.9 19.3 patients, with 31.9% 14.8/34.0% 15.3 being 65 years of age (Table 2). Within this older population, 93.8%/86.6% of optometrists indicated examining ‘‘frail’’ patients in the office, seeing a median of 4.0/2.0 such patients per week. For this survey, frail older patients were defined as those 65 years of age who have polymorbidity, functional impairment, and who rely on others for some activities of daily living [18]. The main reason explaining why some optometrists do not see frail patients, inside or outside the office, is that they have not been contacted to do so. Among respondents, 52.1%/22.1% indicated that they have the special equipment required to perform eye examinations outside the office and 23.7%/7.3% actually see frail older patients outside of the office. They do so at a median of 1.0/2.0 days/month, seeing about 3.0/4.0 patients/month, mainly in LTCF, in assisted living facilities, at the person’s home or at the hospital. Those optometrists were approached by patients’ family consulting at the office, contacted by an institution, or by another professional to request an examination outside of the office for these individuals. Caring for older frail patients often requires interaction with other professionals. Although 31.3%/29.9% of optometrists indicated not having to do so, when a consultation is needed, it is mainly with ophthalmologists, family physicians, physicians or nurses at a LTCF and low-vision centers. While 82.6%/59.0% of optometrists interacting with other professionals do not have difficulty finding the right resource person, an ophthalmologist is most often cited as being difficult to find when a referral for older frail patients is needed.
Table 2 Average percent of patients in the various age categories seen by optometrists in a typical week. Age category (years)
Percentage of patients RoC
Percentage of patients Qc
0–6 7–18 19–64 65
8.8 6.7 16.8 7.8 42.8 14.1 31.9 14.8
7.0 4.8 15.8 7.7 43.7 13.6 34.0 15.3
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When specifically asked if they would consider seeing more older frail patients in their office, 94.3%/88.7% of optometrists answered positively. Furthermore, 41.0%/17.7% would be ready to examine them outside the office. Of the latter, 36.4%/53.6% would accept these patients only on an exceptional basis, while as many as 41.4%/30.9% would accept to do so 0.5 day/month. A minority (8.6%/9.3%) would be willing to offer up to 0.5 day/week. The main reasons given by optometrists for not wanting to see more older frail patients outside the office were that they do not have the time or specialized equipment required to examine these patients adequately, the fact that there is no additional fee or an insufficient fee to take into account the extra time required to adequately serve this population and the lack of a good structural organization to help with the management of these patients (e.g., providing a fully equipped eye examination room, providing support staff to coordinate the appointments and accompany patients). Finally, 38.3%/50.5% of optometrists felt they needed more education in gerontology/geriatrics to help them in the care of older frail patients. The two main areas cited were on the adaptation of the visual examination for these patients and cognitive disorders. However, only 11.2%/18.1% of optometrists indicated that receiving this education would encourage them to increase the number of frail older patients they examine, while another 43.6%/44.3% indicated that it might encourage them.
4. Discussion The focus of this report is to describe the extent of services optometrists offer to older seniors, particularly older frail seniors. Although the data are presented for the rest of Canada and Quebec separately, the intent is not to compare practices between them. However, some comments are provided when large discrepancies exist. The RR obtained between optometrists in the RoC (26.1%) vs. Qc (42.9%) differed substantially, (Table 1) and might be explained by two related factors. First, most optometrists practicing in Quebec were trained in their province at the E´cole d’optome´trie de l’Universite´ de Montre´al (E´OUM) while most optometrists in the rest of Canada were trained at the School of Optometry and Vision Sciences in Ontario. Second, optometrists in Quebec may have a closer relationship with their alma mater considering that a good part of the mandatory continuing education they take on a regular basis is provided at the E´OUM. Quebec optometrists may therefore have replied in greater number to a survey hosted by their School in their province. Although optometrists’ offices see patients mainly by appointment, the majority accept ocular emergencies and about a third have a dropin system. This schedule flexibility is certainly an advantage to patients and should be remembered by older individuals and those caring for them. In particular, optometrists could help older patients with ocular emergencies, thus avoiding a long wait in a hospital emergency room. The optometrist may also be able to help the person obtain a quick appointment with an ophthalmologist if required by their condition or counsel the person if a health problem is detected. However, as many as 17.4% (RoC) and 41% (Qc) of optometrists had difficulty finding another professional when a referral was necessary, indicating a possible lack of care for older frail patients. Most offices are wheelchair accessible and some are adapted for these patients. The environmental adaptations made to an office are particularly important to older patients, in view of the increased vulnerability that may come with age. Elevators, chairs with arms as well as a hard seat and backrest and rails in the bathroom are all elements that will facilitate access to the office, and help older patients once there. Older individuals consulting optometrists represent about a third of their patients although they comprise some 15% of the general population. This indicates the greater need for eye care and that services are available for, and
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used by, individuals in this age group. Our data further indicate that only a minority of older patients seen by optometrists are frail, less than the reported proportion of frail seniors in the older population [19]. This suggests that the vast majority of older patients consulting their primary eye care providers in office are those who are functionally independent in spite of advancing age. The main reason optometrists gave for not seeing more frail patients in the office is that none call for an appointment. This suggests that more information should be available to the public in general, and to the different health organizations caring for frail individuals, regarding the importance of eye care and the eye care services that are available. Optometrists also see older frail patients outside the office (23.7% RoC/7.3% Qc), and a greater proportion would be available to do so if they were asked. This is quite impressive since these data indicate that optometrists are providing services in non-traditional settings even without a supporting health network or adequate fee. This should reassure, but at the same time, challenge health care policy makers. It could effectively be argued that if special adaptations were made, such as providing a fully equipped eye examination room in LTCF, adjusting professional fees to compensate the extra time required to examine these patients, providing support staff to coordinate appointments and accompany the patients to the examination room, optometric services could be further increased for this older frail population. It is important to remember that for this quality of patients, eye care services should be offered in a familiar environment within their respective institutions, particularly if dementia is present, since going outside could increase the risk of behavioral problems and delirium [20,21]. Statistics and demographics clearly indicate that the number of older individuals will rise over the next decades and many will be affected by diseases making them more frail. Many of them, those with advanced dementia among others, will require care at the bedside. Vision is an important component of quality of life [22–24] while visual loss, on the other hand, can contribute to dependency, anxiety, depression, isolation, behavioral problems, delirium and falls [25–29]. Furthermore, ocular pathology leading to visual loss increases with older age. It is therefore important to ensure that these individuals have access to adequate eye care to optimize their vision and, whenever possible, improve their quality of life and decrease the negative effects vision loss may have on their overall health. It is interesting to highlight a few differences that were found between the rest of Canada vs. Quebec. More offices (67.7%/37.0%) in the rest of Canada have been adapted for the needs of older patients, and more frail patients (4.0/2.0) are seen in office every week. Also, more offices in the rest of Canada have the special equipment required to offer eye examinations outside of the office (52.1%/22.1%), and a greater proportion of optometrists actually offer eye care outside the office (23.7%/7.3%), would be willing to do so if asked (41.0%/17.7%), and could offer up to 0.5 day/month (41.4%/30.9%) to care for frail patients. Considering the lower RR obtained in the rest of Canada, it might be that optometrists who responded to our survey were those particularly interested in caring for older adults, including frail seniors. If that were the case, this would have biased the data in favor of optometrists outside Quebec offering more care to frail seniors, while in reality, this difference may not be as great. This could also explain why their offices seem to be better equipped with special instrumentation and better adapted physically for these patients. Also, health care being of provincial jurisdiction, there may exist inter-provincial differences in the organization of eye care services, with advantages in the rest of Canada, facilitating the provision of eye care services outside the office for frail seniors. It is interesting to see that a good proportion of optometrists would like to receive more education to help them with older frail
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patients, but that this would not necessarily increase the proportion of patients they would examine in that category. It might be that those already providing this service would like to improve their knowledge to better serve their patients, without necessarily wanting to increase their number under the current conditions of practice. The principal areas of interest for more education were on how to adapt their visual examination for these patients and cognitive disorders. These two factors may be strongly related. In Canada, the most frail older adults are often aged 75 years and affected by dementia. Dementia affects about 12% and 33% of Canadians aged 65 years and 85 years, respectively [30]. When examining older patients with more advanced dementia, it is important to adapt the examination techniques in order to maximize the response to the tests while minimizing fatigue, anxiety or distress of the person being examined. Data indicate that when these elements are considered, it is possible to provide adequate eye care to older individuals independent of their age, level of cognition or communication abilities [31]. A limitation of the data is that they were self-reported by the optometrists, to the best of their knowledge. It would have been beyond the scope of this project to ask for numbers from patient files, since these statistics may not exist. The optometrists were aware that their data would remain anonymous so there is no reason to suspect misclassification due to a tendency to give more desirable answers.
[2] [3] [4]
[5] [6]
[7] [8]
[9] [10]
[11] [12] [13] [14]
[15]
5. Conclusion In conclusion, older individuals comprise about a third of all patients examined by Canadian optometrists, including a small proportion of frail older patients. Some optometrists are already seeing older frail patients outside the office, and more would be willing to do so if asked. However, under the actual conditions of practice, most optometrists would accept these patients outside the office only on an exceptional basis. Considering that the main reasons for not seeing patients outside the office are lack of adequate fees, instrumentation and structural organization, it would be relevant for governments to explore ways by which such services could be offered with adequate compensation. This is important for meeting the needs of older seniors, considering the growing aging of the population and knowing that frail seniors do not receive optimal eye care in many regions.
[16] [17]
[18] [19]
[20]
[21]
[22]
[23]
Disclosure of interest
[24]
The authors declare that they have no conflicts of interest concerning this article.
[25]
Acknowledgements
[26] [27]
This work was supported by a grant from the Fondation Caroline-Durand [HK and MJK]. The funding source had no involvement in any aspect of the work. We thank all optometrists who helped with the pre-testing of the questionnaire as well as all those who took the time to complete it.
[28]
[29] [30]
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