The prevalence of eye disease in nursing home and non-nursing home geriatric populations

Archives of Gerontology and Geriatrics 28 (1999) 191 – 204

The prevalence of eye disease in nursing home and non-nursing home geriatric populations Joseph W. Eichenbaum a,*, William B. Burton b, Gary M. Eichenbaum a, Michael Mulvihill b b

a Ophthalmology and Ophthalmic Surgery, 1050 Park A6enue, New York, NY 10028, USA Department of Family Medicine, Albert Einstein College of Medicine, 1300 Morris Park A6e, Bronx, NY 10461, USA

Received 13 March 1998; received in revised form 24 December 1998; accepted 28 December 1998

Abstract The objective of this study was to determine whether rates of eye disease among the elderly are higher for residents of nursing homes than for persons who reside elsewhere. Articles reporting the prevalence of eye disease in geriatric populations (classified as nursing home or non-nursing home) were identified through a Medline search and a search of articles’ bibliographies. Identified articles were reviewed, and the relevant data compared with prevalence rates obtained from 738 residents of two nursing homes in New York City. Each of the nursing home residents received an ocular examination upon admission that determined the presence or absence of four varieties of eye disease — i.e. cataracts, age-related macular degeneration, glaucoma, and diabetic retinopathy. Demographic data were obtained through chart review. Results indicate that prevalence rates of eye disease found in geriatric nursing home populations are generally higher than those found in other geriatric populations. With the exception of the rates for diabetic retinopathy, the rates found in the combined nursing home population sampled in this study were much higher than those reported in any previous study. It is concluded that eye disease is a more serious problem for elderly residents of nursing homes than for the elderly who reside in the community. Possible reasons for this are discussed. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Eye diseases; Prevalence; Nursing homes; Geriatrics

* Corresponding author. Tel.: +1-212-2897200; fax: +1-212-2897474. 0167-4943/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 7 - 4 9 4 3 ( 9 9 ) 0 0 0 0 9 - 6

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1. Introduction As both the total population and life expectancy in the United States continue to rise, the geriatric population has grown both in absolute numbers and as a proportion of the general population (Schick and Schick, 1994). These increases have been matched by a similarly dramatic rise in the number of nursing home residents (going from 473 358 in 1960 to 1 777 032 in 1990), the large majority of whom are over the age of 65. Given these trends, which are expected to continue for several decades, there is a need to better understand the epidemiology of eye disease among the elderly and to provide ophthalmologic care for this rapidly growing sector of the population (Hyman, 1987; Dougherty et al., 1994). Many types of eye disease, including age-related macular degeneration (AMD), diabetic retinopathy, glaucoma, and cataracts, are especially prevalent among the elderly (Canadian Task Force on the Periodic Health Examination, 1995; Sperduto and Seigel, 1980; Podger et al., 1983; Hyman, 1987; Klein et al., 1992a,b,c, 1997). In the United States, AMD is the leading cause of blindness among persons 52 years or older, and approx. 2.2% of the population over the age of 65 are blind in one or both eyes as a result of AMD (American Academy of Ophthalmology, 1990). Diabetic retinopathy is the leading cause of new cases of legal blindness among Americans between the ages of 20 and 74 (American Academy of Ophthalmology, 1993). Glaucoma affects 10% of elderly African Americans and 2% of elderly Caucasians (American Academy of Ophthalmology, 1995). Cataracts are diagnosed in about 10% of Americans, but the prevalence increases to 50% between the ages of 65 and 74 and 70% over the age of 75 (American Academy of Ophthalmology, 1996). Pizzarello (1987) notes that the risk of blindness from all causes is 10 times greater for the elderly than for the non-elderly. Surprisingly, visual deficits in the elderly often go unrecognized by individuals and their physicians (McMurdo and Baines, 1988; Long et al., 1991; Wormald et al., 1992), and a large portion of them do not obtain necessary eye care (Wang and Javitt, 1996). This is true despite the fact that vision problems have been found to have a major impact on the quality of life of the elderly (Legro, 1991; Brenner et al., 1993). Residents of nursing homes may be at especial risk, because they often do not have the same access to health care as do persons living at home (Newell and Walser, 1985; Goetzinger et al., 1996). Some evidence suggests that residents of nursing homes have a higher prevalence of eye disease than their chronological peers living outside nursing homes (Whitmore, 1989). For example, Tielsch et al. (1995a) found that the rate of blindness among nursing home residents was 13–15 times higher than among a communitydwelling sample of similar age from the same area. The present study addresses this issue by comparing the prevalence of four types of eye disease (i.e. cataracts, AMD, glaucoma, and diabetic retinopathy) found in two nursing homes with the prevalences reported in earlier studies, some of which were conducted inside nursing homes and some of which were conducted outside of nursing homes. In addition, the possible comorbidity of cataracts and macular degeneration will be explored, as a positive relationship between these two diagnoses has been found previously

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among the elderly (Tielsch et al., 1995b; Willerscheidt et al., 1995; American Academy of Ophthalmology, 1996).

2. Materials and methods

2.1. Subjects The patients in this study were residents of two nursing homes: one, a for-profit facility, and the other, a non-profit facility. Three-fourths of the residents of the for-profit nursing home were African American, with the remainder 20% Latino and 5% Caucasian. Three-fourths of the residents of the non-profit home were Caucasian, with the remainder equally divided amongst African American, Latino, or other descent. The requirements for home admission in both settings included the absence of communicable infectious disease, the appropriate health insurance required for each home, and any additional financial requirements stipulated in each setting. No visual or mental status or sustained self-sufficiency requirements were mandated prior to admission in either setting. Of the 732 patients in both nursing homes, 90% were ambulatory and 10% were wheelchair or bed bound. Only a rare patient in approximately every 10th clinic week required hyperalimentation or intravenous therapy on a chronic basis. These patients were examined at the bedside. The other ambulatory patients were examined after having been escorted to the eye clinic at each nursing home. All the data for this study were collected from chart notes either dictated or hand written by the first author after each patient’s exam. The examinations took place between January 1991 and 1992. The format for recording included: (1) subjective complaint(s); (2) objective ophthalmologic and systemic findings, including pertinent laboratory data; (3) diagnosis; and (4) treatment(s). Each patient’s name, age, nursing home residence, and diagnosis ICDA numbers were entered into a computer spread sheet.

2.2. Examination methodology All residents underwent admission as well as necessary follow-up ocular examinations by the first author. When not precluded by the presence of significant organic mental syndrome, the first author performed manifest refractions at one nursing home and another doctor performed the manifest refractions at the second nursing home. Other parts of the ophthalmologic exam included: oculomotor ability, hand held slit lamp and applanation tonometry, and dilated funduscopic examination when the patient consented and narrow angle glaucoma did not contravene. New glasses were provided by the nursing home when the new measurement improved the patient’s visual acuity. The last data sets of diagnostic findings on each patient were culled and used for this study. Diagnostic categories were created as follows: A diagnosis of cataract was made when on slit lamp exam capsular, cortical, or nuclear opacity was noted

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to interfere with slit beam passage. Aphakia and pseudophakia were also listed under the category of cataract. A diagnosis of AMD, or adult onset macular degeneration, was made when the macular retinal pigment epithelium was atrophic, irregularly clumped, dispersed, mottled with an irregular pattern or color, littered with drusen over the fovea, and/or exhibited thickness or elevation as in subretinal neovasularization and/or subretinal leakage. Patients with organic mental syndrome that precluded accurate visual acuity responses on subjective testing were included in the AMD group when the above funduscopic criteria were observed. In about 10% of the cases, where foveal and perifoveal drusen were not increasingly confluent nor enlarging in character but the corrected visual acuity was observed to diminish over time, the patients were brought to the office for laser interferometry and, when necessary, florescein angiography, in order to ascertain whether the decrease was caused by the progression of cataracts or macular degeneration. In such cases, a finding of decreased visual acuity performance on laser interferometry led to a diagnosis of macular degeneration. If the magnitude of the cataract on slit lamp examination was not commensurate with reduction of best corrected visual acuity and laser interferometry was inconclusive, then florescein angiography was performed. Angiographic criteria for diagnosing macular degeneration included subretinal neovascular leakage, pertinent macula and perimacular window defects, macular and perimacular drusen, and perifoveal capillary perfusion defects sufficient to relate to the patient’s symptoms. Patients who had both cataracts and macular degeneration contributing to the visual complaints were given diagnoses of both etiologies. However, patients who had predominantly, e.g. cataracts with only subtle macular pigment epithelial irregularities of aging and some residual foveal reflex were only given the diagnosis of cataracts. Alternatively, patients who had only trivial homogenous nuclear sclerosis of the lens but disciform macular scars were diagnosed with macular degeneration. A diagnosis of open-angle glaucoma was made when the intraocular pressure by applanation tonometry was greater than 21 mmHg on three occasions, the angle was gonioscopically open 20% or greater for structure visibility (to the top of the ciliary body) in two or more quadrants Zeiss goniomirror, the cup:disc ratio was 0.5 or greater (or a cup:disc ratio asymmetry of 0.2 or greater was found in the eye with the greater elevation of ocular pressure), and, where possible, tangent screen testing showed nasal and or temporal steps or arcuate fiber bundle field cuts. Narrow-angle glaucoma was diagnosed either on the basis of gonioscopic narrowing of greater than 20%, prior history or either laser or surgical iridectormy for narrow-angle glaucoma, or additional clinical findings such as chronic uveitis, large peripheral anterior synechiae, or a frank closed angle glaucoma attack was manifested clinically. Rare cases of mixed mechanism and/or secondary glaucoma, e.g. diabetic neovascular, post traumatic, post surgical, etc. were included under the ICDA code of open-angle glaucoma. Patients with diabetic retinopathy had a history of diabetes mellitus and one or more of the following: dot blot or flame-shaped hemorrhages, microaneurysms, exudates, macular edema, or neovascularization. Anterior ischemic neuropathy was

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diagnosed in the setting of painless acute drop in visual acuity, ischemic optic nerve changes, a cup:disc ratio difference of 0.2 between the two eyes and altitudinal field defect to confrontation or tangent screen. Arteritic ischemic optic neuropathy was considered in the setting of painful loss of vision, temple headache, jaw claudication, elevated sedimentation count, narrowed arterioles, hemorrhages, disc pallor, and positive temporal artery biopsy, or in some cases where the biopsy was negative but the patient was deemed clinically positive by rheumatologic and ophthalmologic consultation.

2.3. Methodology of literature re6iew We conducted a thorough review of published studies that reported prevalences of eye disease in geriatric populations. Published reports had to meet three criteria in order to be included in the present study. First, they had to report prevalences of one or more of the following eye diseases—cataracts, AMD, glaucoma, and diabetic retinopathy. Second, they had to report prevalence rates for one or more of the following age categories: 65, 65–74, 75–84, 85. Third, studies reporting prevalences of diabetic retinopathy were excluded if they looked only at diabetic patients. A computer search was conducted using Medline software (reference) based on the following keywords: geriatrics, aged, nursing home, eye disease, cataract, macular degeneration, glaucoma, and diabetic retinopathy. The bibliographies of studies that were located were also scanned for additional studies that had not appeared in the computer search. Unfortunately, several studies, many of them European, had to be excluded because they used a different method of categorizing age (i.e., 60 – 69, 70 – 79, 80 – 89). Minor variations in the age categories, however, were allowed (see footnotes to Tables 3–6).

3. Results Most of the patients in the mixed nursing home population were still ambulatory. In fact, when approached in a kind and non-confrontational manner with regard to ‘checking their eyes’ after they were brought to the eye clinic or if seen at the bedside, the majority were visually attentive and responsive. They permitted hand-held applanation tonometry and biomicroscopy. Reliable Snellen visual acuity, however, could only be attained in approx. 15% of the patients because of inability to concentrate or organic mental syndrome. Data were collected on 431 patients in the for-profit nursing home and 301 patients in the non-profit nursing home. Of the combined 732 patients in the study, 542 (73.4%) were female and 190 (26.6%) were male. The average age of patients was 83.5. For males, the average age was 81.1, with a range of 51 to 101 years. For females, the average age was 84.3, with a range of 32 to 112 years. In order of prevalence, the following rates of ocular disease were observed: cataracts (82.5%), AMD (70.7%), glaucoma (41.4%), disorders of the optic nerve (12.9%), inflammation of the eyelid (12.8%), other disorders of the eyelid (7.3%),

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conjunctiva (6.8%), and diabetic retinopathy (1.7%). Table 1 shows the prevalence of ocular disease by gender. No significant gender differences were observed. All additional analyses will be limited to: (a) the diagnoses of cataracts, AMD, glaucoma, and diabetic retinopathy, as prevalences for these diseases are most commonly reported in the literature; and (b) nursing home residents who are 65 years of age or older. Table 2 presents information concerning the setting, population, and disease focus of each study that was located in the literature review of eye disease in geriatric populations. The 36 studies that matched the inclusion criteria are listed chronologically, and are sorted according to whether they addressed nursing home or non-nursing home populations. Eight studies (Kornzweig et al., 1957; Newell and Walser, 1985; Rifaat and Kivela, 1989; Whitmore, 1989; Ho et al., 1990; Perasalo and Raitta, 1992; Perasalo, 1994; Mitchell et al., 1997), all but three of which were conducted outside of the US, surveyed residents of nursing homes. The other 28 studies surveyed populations other than nursing home residents (Hollows and Graham, 1966; McWilliam, 1975; Kahn et al., 1977; Kini et al., 1978; Liebowitz et al., 1980; Sperduto and Seigel, 1980; Bengtsson, 1981; Martinez et al., 1982; Ferris, 1983; Ganley and Roberts, 1983; Leske and Sperduto, 1983; Podger et al., 1983; Hakkinen, 1984; Gibson et al., 1985; Jonasson and Thordarson, 1987; Vinding, 1989; Ringvold et al., 1991; Klein et al., 1992a,b,c; Pauleikhoff et al., 1992; Wu, 1992; Mitchell, 1993; Dougherty et al., 1994; Mitchell et al., 1995; Vingerling et al., 1995; Gray, 1996; Cruickshanks et al., 1997; Klein et al., 1997 Table 3 through to Table 6 display prevalences for the four categories of eye disease reported in the literature (including the present study), split by age. These data clearly indicate that wide variability in prevalence exists within any single type of disease, which is probably related in large part to the use of different diagnostic criteria and methodologies (e.g. questionnaire versus direct exam). If one focuses only on the prevalence rates listed under the age 65 columns in Tables 3 – 5 and Table 6, the highest prevalence rates are found in those studies that surveyed residents of nursing homes. Focusing on these rates is perhaps misleading, however, because nursing home populations are likely to have higher proportions of the very elderly than are non-institutionalized populations. If one focuses instead Table 1 Prevalence of eye disease by gender Eye disease

Female

Male

Cataracts AMD Glaucoma Disorders of the optic nerve Inflammation of eyelid Other disorders of eyelid Conjunctiva Diabetic retinopathy

83.4 70.2 40.6 13.2 13.0 7.6 6.2 1.9

82.1 72.8 41.5 10.3 10.8 5.6 7.7 1.0

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Table 2 Summary of prevalence studies of eye disease in the elderly First author (date)

Country

Nursing home populations Kornzweig (’59) USA Newell (’85) USA Rifaat (’89) Finland Whitmore (’89) USA Ho (’90) Singapore Perasalo (’92) Finland Perasalo (’94) Finland Mitchell (’97) Australia Non-nursing home populations Hollows (’66) UK McWilliam (’75) UK Kahn (’77) USA Kini (’78) USA Liebowitz (’80) USA Sperduto (’80) USA Bengtssom (’81) Sweden Martinez (’82) New Zealand Ferris (’83) USA Ganley (’83) USA Leske (’83) USA Podgor (’83) USA Hakkinen (’84) Finland Gibson (’85) Jonasson (’87) Vinding (’89) Ringvold (’91) Klein (’92a) Klein (’92b) Klein (’92c) Pauleikhoff (’92) Wu (’92) Mitchell (’93) Dougherty (’94) Mitchell (’95) Vingerling (’95) Gray (’96) Cruickshanks (’97) Klein (’97)

UK Iceland Denmark Norway USA USA USA UK China Australia USA Australia Netherlands UK USA USA

Population/setting

Diseases*

1068 604 268 225 546 100 213 128

Residents Residents Residents Residents Residents Residents Residents Residents

C, G, G C, G, C, G, C G G, M C, G,

4231

Three Welsh villages

n

2477 2675 2477 2477 599 481 2477 10,126 2631 2477 Residents of town 484 751 1000 1941 4926 4926 4926 430 3351 3283 429 3654 6251 167 5540 3583

of of of of of of of of

home for aged nursing home nursing home nursing home home for aged nursing home nursing home nursing home

G C Survivors of heart study C, Survivors of heart study C, Survivors of heart study C, Survivors of heart study M Residents of village G Random sample of population C, Survivors of heart study Random sample of population C, Survivors of heart study C Survivors of heart study C, M Random sample of population Residents of rural area Random sample of population Residents of three towns Residents of town Residents of town Residents of town Residents of town Residents of district Residents of region Users of mobile eye clinic Residents of suburb Residents of suburb Immigrants in public housing All residents of two towns Residents of town

M, D M, D M, D

M

G, M, D G, M, D G, M, D

G, M, D G, M, D G, M, D

C, G, M C, G, M M G C G M M M M C, G, M M M C M M

* C, cataracts; G, glaucoma; M, age-related macular degeneration, or AMD, D, diabetic retinopathy.

on the values listed under the separate age groups (i.e. 65–74, 75–84, and 85), the prevalence rates obtained in nursing homes still tend to be among the highest found in each disease category. With the exception of the rates obtained in the present study, however, the eye disease prevalence rates in nursing homes are not consistently the highest, compared with non-nursing home groups.

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4. Discussion Due to the inherent variability in any epidemiological study, including examination techniques, diagnosis definitions, patient demographics, environment and other unknown factors (Ederer, 1983; Whitmore, 1989), patients selected in one study may not be entirely comparable to patients selected in other studies. Nonetheless, a comparison of the results of studies conducted in nursing homes with the results of studies conducted in non-nursing home settings provides some evidence that eye disease is a more serious problem in the former. With the exception of the prevalence rate for diabetic retinopathy, the rates of eye disease obtained in the present study are far higher than the rates obtained in any previous study, nursing home or otherwise. There are many possible reasons for this. The first is an ‘examiner effect’—i.e. the examining physician may have been biased toward applying a diagnosis of disease where none existed. This seems unlikely, however, since the diagnostic criteria used in this study were consistent with those used in earlier studies. The use of a portable slit lamp tonometer and indirect ophthalmoscopy may also have helped data gathering. A second possibility Table 3 Prevalence (%) of cataracts in geriatric populations First author (date)

Nursing home population Kornzweig (’57) Rifaat (’89) Whitmore (’89) Ho (’90) Eichenbaum (’97) Mitchell (’97) Non-nursing home population McWilliam (’75) Kahn (’77)* Kini (’78)* Liebowitz (’80)* Martinez (’82) Ganley (’83) Leske (’83) Gibson (’85) Jonasson (’87)** Klein (’92a) Dougherty (’94)*** Gray (’96)

Age ]85

65–74

75–84

25.0 11.1

43.0 55.7

67.4

93.2

80.8

80.1

14.0 13.2 18.1 9.7 18.8 28.4 28.5 21.2 24.0 33.8

40.8 46.1 33.7 52.1

30–42 59.8 52.2 69.1

71.0

44–65 100.0 89.1

* Second age group was 75–85. Study was limited to persons less than 86 years of age. ** Age groups were 63–72, 73–82, \82. *** Second age group was 75–85; third age group was \85.

]65

60.9 31.0 59.2 32–45 82.4 14.0

22.4 27.4 24.5 30.1

46.1 41.2 34.0 59.0 53.3

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Table 4 Prevalence (%) of AMD in geriatric populations First author (date)

Age 75–84

]85

]65

44.0 5.6 76.7

63.0 20.0 69.2

29.6 69.9

51.9 24.7 70.7 12.0

7.0 11.0 4.1 47.0 2.1 11.1 8.5 27.4

21.7 27.9 15.4 50.0 11.1 28.0

18.8

27.7 28–29 22.2 27.3 44.3 c

65–74 Nursing home population Rifaat (’89) Whitmore (’89) Eichenbaum (’97) Mitchell (’97) Non-nursing home population Kahn (’77)* Kini (’78)* Liebowitz (’80)* Sperduto (’80) Martinez (’82) Ferris (’83) Ganley (’83) Podger (’83) Hakkinen (’84) Mitchell (’84) Gibson (’85) Jonasson (’87)** Vinding (’89)*** Klein (’92c) Pauleikhoff (’92) Wu (’92) Mitchell (’93) Dougherty (’94) c c Mitchell (’95) Vingerling (’95) Cruickshanks (’97) c c c

5.1 8.9 23.9

14.8 9.7 0.7 4.0 10.4–14.3

11.9 16.7 11.5 22.8

6.4

43.0

18.8 24.1 5.4 6.1

60.0 38.3 36–53 48.8

25.7 38.2 18.5 9.0

25.0 41 12.6 15.2 31.3 25.0 16.8 1 20.7 7.3 5.1

* Second age group was 75–85. Study was limited to persons less than 86 years of age. ** Age groups were 63–72, 73–82, \82. *** Second age group was 75–80. Study was limited to personsB81 years of age. c Prevalence rate pertains to all persons above the age of 74. cc Second age group was 75–85; third age group was\85. ccc Prevalence rates of non-Hispanic Whites between the ages of 60–74.

has to do with socioeconomic factors. Most of the studies in the literature review focused on middle-class populations. In contrast, the residents of one of the nursing homes included in the present study (from which the majority of the data was drawn) had predominantly indigent Medicaid patients admitted especially for medical care, which had been less than adequately addressed previously. A substantial percentage of these patients may not have been exposed to medical care at all in the past, in addition to having poorer nutritional states and life circumstances. This explanation seems to be supported by the fact that prevalence rates from the nursing home with residents of lower socioeconomic background were consistently

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higher than the prevalence rates from the nursing home with residents of higher socioeconomic background, especially in regard to glaucoma. While exact information on the residents’ race, ethnicity, education, and income was not recorded during the chart reviews, the majority of the patients in the for-profit nursing home were of African-American origin. It is clear from other inner-city studies that socioeconomic status (Tielsch et al., 1991) and race (Tielsch et al., 1990) are strongly, and independently, related to reduced vision. Unfortunately, the possible relationship between these variables and the prevalence of eye disease could not be explored in the present study. The comorbidity of cataracts and macular degeneration in patients was not found in this study. However, the prevalences of cataracts and AMD in each of the age groups studied are disproportionately high. The lack of correspondence with what has been clinically known and accepted is difficult to explain. It is possible that such a relationship would have emerged had the study population been larger, or had the study been conducted across a longer period of time. Table 5 Prevalence (%) of glaucoma in geriatric populations First author (date)

Age 65–74

Nursing home population Kornzweig (’57) Newell (’85) Rifaat (’89) Whitmore (’89)* Perasalo (’92) Perasalo (’94) Eichenbaum (’97) Mitchell (’97) Non-nursing home population Hollows (’66) Kahn (’77)** Kini (’78)** Liebowitz (’80)** Bengtsson (’81) Martinez (’82) Ganley (’83) Gibson (’85) Jonasson (’87) Ringvold (’91) Klein (’92) Dougherty (’94)***

75–84

3.2

7.4

45.6

35.1

13.2 4.1 5.1 1.7 2.0 4.2 4.0

4.0 7.2 2.9 5.0 2.6

4.7 11.9 2.7 5.8

5.2–7.1 20.5 18.9 5.5

85

43.8

65

10.2 15.8 4.9 11.0 15.0 32.0 41.3 10.0

4.1 5.8 2.3 10.0 6.8 2.9–4.3 16.3 31.8 10.9

* Includes two residents who were under the age of 65. ** Second age group was 75–85. Study was limited to persons less than 86 years of age. *** Second age group was 75–85; third age group was\85.

3.6 6 10.6 16.6 3.4 6.3

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Table 6 Prevalence (%) of diabetic retinopathy in geriatric populations First author (date)

Age 65–74

75–84

Nursing home population Kornzweig (’57) Rifaat (’89) Whitmore (’89)* Eichenbaum (’97)

3.2

1.9

4.9

0.5

Non-nursing home population Kahn (’77)** Kini (’78)** Liebowitz (’80)** Martinez (’82)

2.5 2.9 1.7

5.8 7.0 3.0

]85

]65

1.4

11.1 2.6 2.4 1.6

3.6 4.3 2.3 0.5

* Includes two residents who were under the age of 65. ** Second age group was 75–85. Study was limited to persons less than 86 years of age.

The findings of this study suggest that eye disease is a more serious problem for elderly residents of nursing homes than for the elderly who reside in the community. There are a number of possible reasons for this. First, individuals are typically admitted to nursing homes for problems related to their inability to function independently outside, and visual impairments are certainly among the most important causes of this inability (Mitchell et al., 1997). As stated by Tielsch et al. (1995a), ‘severe vision loss may be an unrecognized contributor to the decline in patients’ cognitive function and in their ability to care for themselves, which increases the likelihood of admission to a nursing home.’ Second, eye disease has been found to be comorbid with other chronic diseases, the latter of which may be the precipitant of admission to the nursing home (van de Lisdonk et al., 1992). Third, confinement in an institutional environment itself may lead to physical decrements, as a result of sensory deprivation, reduced levels of physical and mental activity, etc. (Mishara, 1979).

References American Academy of Ophthalmology, 1990. Preferred practice patterns: macular degeneration. American Academy of Ophthalmology, San Francisco. American Academy of Ophthalmology, 1993. Preferred practice patterns: diabetic retinopathy. : American Academy of Ophthalmology, San Francisco. American Academy of Ophthalmology, 1995. Preferred practice patterns: primary open-angle glaucoma suspect. American Academy of Ophthalmology: San Francisco. American Academy of Ophthalmology, 1996. Preferred practice patterns: cataract in the adult eye. American Academy of Ophthalmology, San Francisco. Bengtsson, B., 1981. Manifest glaucoma in the aged I: occurring nine years after a population survey. Acta Ophthalmol. 59, 321–331.

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Brenner, M.H., Curbow, B., Javitt, J.C., Legro, M.W., Sommer, A., 1993. Vision change and quality of life in the elderly: response to cataract surgery and treatment of other chronic ocular conditions. Arch. Ophthalmol. 111, 680–685. Cruickshanks, K.J., Hamman, R.F., Klein, R., Nondahl, D.M., Shetterly, S.M., 1997. The prevalence of age-related maculopathy by geographic region and ethnicity. Arch. Ophthalmol. 115, 242 – 250. Dougherty, P.J., Engelhardt, R.F., Lee, D.A., 1994. Eye disease among ambulatory Jewish senior citizens in California. J. Community Health 19, 271 – 284. Ederer, F., 1983. Methodological problems in eye disease epidemiology. Epidemiol. Rev. 5, 51 – 66. Ferris, F.L., 1983. Senile macular degeneration: review of epidemiologic features. Am J Epidemiol. 118, 132–151. Ganley, J.P., Roberts, J., 1983. Eye conditions and related need for medical care. Vital and Health Statistics, Data from the National Health Survey, Series 11, No. 228. Gibson, J.M., Rosenthal, A.R., Lavery, J., 1985. A study of the prevalence of eye disease in the elderly in an English community. Trans. Ophthalmol. Soc. UK 104, 196 – 203. Goetzinger, G.J., Wingert, T.A., McAlister, W.H., 1996. Routine optometric care in nursing homes: a retrospective study. Optom. Vis. Sci. 73, 243 – 246. Gray, P.J., 1996. The prevalence of eye disease in elderly Bengalis in Tower Hamlets. J. R. Soc. Med. 89, 23–26. Hakkinen, L., 1984. Vision in the elderly and its use in the social environment. Scan. J. Soc. Med. Suppl. 35, 5–60. Ho, S.C., Donnan, S., Ho, P.C., Lai, J.S., 1990. Prevalence of cataract among the institutionalized elderly in Hong Kong. Singapore Med. J. 31, 308 – 310. Hollows, F.C., Graham, P.A., 1966. Intra-ocular pressure, glaucoma and glaucoma suspects in a defined population. Acta Ophthalmol. 50, 570 – 590. Jonasson, F., Thordarson, K., 1987. Prevalence of ocular disease and blindness in a rural area in the eastern region of Iceland during 1980 through 1984. Acta Ophthalmol. 65, 40 – 43. Hyman, L., 1987. Epidemiology of eye disease in the elderly. Eye 1, 330 – 341. Kahn, H.A., Leibowitz, H.M., Ganley, J.P., Kini, M.M., Colton, T., Nickerson, R.S., 1977. The Framingham Eye Study. I. Outline and major prevalence findings. Am. J. Epidemiol. 106, 17 – 32. Kini, M.M., Leibowitz, H.M., Colton, T., Nickerson, R.J., Ganley, J., Dawber, T.R., 1978. Prevalence of senile cataract, diabetic retinopathy, senile macular degeneration, and open-angle glaucoma in the Framingham Eye Study. Am. J. Ophthalmol. 85, 28 – 34. Klein, B.E.K., Klein, R., Linton, K.L., 1992a. Prevalence of age-related lens opacities in a population: the Beaver Dam Eye Study. Ophthalmology 99, 546 – 552. Klein, B.E.K., Klein, R., Sponsel, W.E., Franke, T., Cantor, L.B., Martone, J., 1992b. Prevalence of Glaucoma: the Beaver Dam Eye Study. Ophthalmology 99, 1499 – 1504. Klein, R., Klein, B.E.K., Linton, K.L.P., 1992c. Prevalence of age-related maculopathy: the Beaver Dam Eye Study. Ophthalmology 99, 933–943. Klein, R., Klein, B.E.K., Jensen, S.C., Meuer, S.M., 1997. The five-year incidence and progression of age-related maculopathy. Ophthalmology 104, 7 – 22. Kornzweig, A.L., Feldstein, M., Schneider, J., 1957. The eye in old age. IV. Ocular survey of over one thousand aged persons with special reference to normal and disturbed visual function. Am. J. Ophthalmol. 44, 29–37. Legro, M.W., 1991. Quality of life and cataracts: a review of patient-centered studies of cataract surgery outcomes. Ophthalmic Surg. 22, 431– 443. Leske, M.C., Sperduto, R.D., 1983. The epidemiology of senile cataracts: a review. Am. J. Epidemiol. 118, 152–165. Liebowitz, H.M., Krueger, D.E., Maunder, L.R., Milton, R.C., Kini, M.M., Kahn, H.A., Nickerson, R.J., Pool, J., Colton, T.L., Ganley, J.P., Loewenstein, J.I., Dawber, T.R., 1980. The Framingham Eye Study Monograph. Surv. Ophthalmol. 24, Suppl (May – June). Long, C.A., Holden, R., Mulkerrin, E., Sykes, O., 1991. Opportunistic screening of visual acuity of elderly patients attending outpatient clinics. Age Ageing 20, 392 – 395. Martinez, G.S., Campbell, A.J., Reinken, J., Allan, B.C., 1982. Prevalence of ocular disease in a population study of subjects 65 years old and older. Am. J. Ophthalmol. 94, 181 – 189.

J.W. Eichenbaum et al. / Arch. Gerontol. Geriatr. 28 (1999) 191–204

203

McMurdo, M.E.T., Baines, P.S., 1988. The detection of visual disability in the elderly. Health Bull. 46, 327–329. McWilliam, R.J., 1975. Ophthalmologic results from a geriatric assessment survey. Trans. Ophthalmol. Soc. UK 95, 71–73. Mishara, B.L., 1979. Environment and face-hand test performance in the institutionalized elderly. J. Gerontol. 34, 692–696. Mitchell, P., Hayes, P., Wang, J.J., 1997. Visual impairment in nursing home residents: the Blue Mountains Eye Study. Med. J. Australia 166, 73 – 76. Mitchell, P., Smith, W., Attebo, K., Healey, P.R., 1995. Prevalence of age-related maculopathy in Australia: the Blue Mountains Eye Study. Ophthalmology 102, 1451 – 1460. Mitchell, R.A., 1993. Prevalence of age related macular degeneration in persons aged 50 years and over resident in Australia. J. Epidemiol. Community Health 47, 42 – 45. Newell, S.W., Walser, J.J., 1985. Nursing home glaucoma and visual acuity screening results in Western Oklahoma. Ann. Ophthalmol. 17, 186 – 189. Pauleikhoff, D., Wormald, R.P., Wright, L., Wessing, A., Bird, A.C., 1992. Macular disease in an elderly population. German J. Ophthalmol. 1, 12 – 15. Perasalo, R., 1994. The prevalence of macular degeneration in a cohort of institutionalized geriatric glaucoma patients. Acta Ophthalmol. 72, 175 – 177. Perasalo, R., Raitta, C., 1992. The prevalence and type of glaucoma in geriatric patients. Acta Ophthalmol. 70, 308–311. Pizzarello, L.D., 1987. The dimensions of the problem of eye disease among the elderly. Ophthalmology 94, 1191–1195. Podger, M.J., Leske, M.C., Ederer, F., 1983. Incidence estimates for lens changes, macular changes, open angle glaucoma and diabetic retinopathy. Am. J. Epidemiol. 118, 206 – 212. Rifaat, R., Kivela, S.L., 1989. Occurrence of eye disorders and need for treatment in the elderly in nursing homes. Acta Ophthalmol. 67, 657 – 663. Ringvold, A., Blika, S., Elsas, T., Guldahl, J., Brevik, T., Hesstredt, P., Hoff, K., Hoisen, H., Kjorsvik, S., Rossvold, I., 1991. The middle-Norway eye-screening study. II. Prevalence of simple and capsular glaucoma. Acta Ophthalmol. 69, 273 – 280. Schick, F.L., Schick, R., 1994. Statistical Handbook on Aging Americans. Oryx Press, Phoenix. Sperduto, R.D., Seigel, D., 1980. Senile lens and senile macular changes in a population-based sample. Am. J. Ophthalmol. 90, 86–91. Tielsch, J.M., Javitt, J.C., Coleman, A., Katz, J., Sommer, A., 1995a. The prevalence of blindness and visual impairment among nursing home residents in Baltimore. New Eng. J. Med. 332, 1205 – 1209. Tielsch, J.M., Sommer, A., Katz, J., Quigley, H., Ezrine, S., 1991. Socioeconomic status and visual impairment among urban Americans. Arch. Ophthalmol. 109, 637 – 641. Tielsch, J.M., Sommer, A., Witt, K., Katz, J., Royall, R.M., 1990. Blindness and visual impairment in an American urban population: the Baltimore Eye Survey. Arch. Ophthalmol. 108, 286 – 290. Tielsch, J.M., Steinberg, E.P., Cassard, S.D., Schein, O.D., Javitt, J.C., Legro, M.W., Bass, E.B., Sharkey, P., 1995b. Preoperative functional expectations and postoperative outcomes among patients undergoing first eye cataract surgery. Arch. Ophthalmol. 13, 312 – 1318. van de Lisdonk, E.H., Furer, J.W., Kroonen, A.P., Marijnissen, A.G., 1992. Cataract, functioning and comorbidity: a cross-sectional study in family practice. Fam. Pract. 9, 279 – 283. Vinding, T., 1989. Age-related macular degeneration: macular changes, prevalence and sex ratio: an epidemiological study of 1000 aged individuals. Acta Ophthalmol. 67, 609 – 616. Vingerling, J.R., Dielemans, I., Hofman, A., Grobbee, D.E., Hijmering, M., Kramer, C.F., de Jong, P.T., 1995. The prevalence of age-related maculopathy in the Rotterdam study. Ophthalmology 102, 205–210. Wang, F., Javitt, J.C., 1996. Eye care for elderly Americans with diabetes mellitus: failure to meet current guidelines. Ophthalmology 103, 1744 – 1750. Whitmore, W.G., 1989. Eye disease in a geriatric nursing home population. Ophthalmology 96, 393–398. Willerscheidt, A.B., Healey, M.L., Ireland, M., 1995. Cataract surgery outcomes: importance of comorbidities in case-mix. J. Cataract. Refract. Surg. 121, 177 – 181.

204

J.W. Eichenbaum et al. / Arch. Gerontol. Geriatr. 28 (1999) 191–204

Wormald, R.P., Wright, L.A., Courtney, P., Beaumont, B., Haines, A.P., 1992. Visual problems in the elderly population and implications for services. Br. Med. J. 304, 1226 – 1229. Wu, Z.Q., 1992. Epidemiologic survey of senile macular degeneration. Chin. J. Ophthalmol. 28, 246–247.

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