Quality Indicators for the Care of Vision Impairment in Vulnerable Elders

Vision impairment is common in elderly people, and it increases with age. Population-based studies report functional visual impairment in 4% to 7% of persons aged 71 to 74, 16% of persons aged 80 and older, and 39% of persons aged 90 and older. Similarly, the Beaver Dam Eye Study found visual impairment worse than 20/40 vision in 5% of individuals aged 65 to 74 and 21% of individuals aged 75 and older. Approximately 90% of the population aged 65 and older requires refractive lenses to optimize vision. It is estimated that more than half of these individuals would experience better vision from alteration of refractive lenses or other appropriate treatment. Decreased vision is debilitating for elderly people. Of those aged 60 and older, distance visual acuity of 20/25 or worse is associated with greater risk of falls and fractures than for those with 20/20 or better vision. Reduced useful visual field has been associated with greater risk of motor vehicle crashes in older drivers. Worse visual function has been shown to be associated with limitations in mobility, activities of daily living (ADLs), and physical performance. Declines in subjective visual function have major negative effects on cognitive, affective, and functional status and increase the probability of nursing home residence. Functional-status and quality-of-life measurements in ophthalmic patients are lower than for controls with normal vision and no known ocular disease. Quality-of-life studies specific to cataract, glaucoma, diabetic retinopathy, and macular degeneration have all shown significantly poorer vision-related quality of life associated with vision loss from these diseases. Studies have shown that distance visual impairment worse than 20/40 is associated with a decrease across all self-reported measures of functional status in those aged 65 and older. Effective treatment or prevention is available for much of the visual disability due to common eye disorders. For example, although no randomized trials or case-control studies have proven the benefit of eyeglasses for refractive error, there is widespread consensus that functional disability due to refractive error is largely resolved using corrective lenses. Cataract extraction is also highly effective in patients with visual loss due to cataracts. Studies of patients undergoing cataract surgery showed that, by 1 year after surgery, 95% to 96% of the patients experienced improved Snellen visual acuity, and 80% to 89% experienced improved ability to perform vision-related ADLs. These patients also experienced fewer declines in overall health-related quality of life than expected. An observational evaluation of Medicare beneficiaries representative of the U.S. population demonstrated that patients with more-regular eye examinations were less likely to experience a decline in visual function or functional status over a 5-year period. Patients with advanced eye disease also can benefit from intervention. For example, for patients with diabetic retinopathy, laser treatment has been shown to reduce vision loss 50% or more, whereas many individuals with glaucomatous vision loss who undergo appropriate pressure-lowering treatments are able to reduce progression of their disease 20% to 40%. Of patients with treatable macular degeneration, antioxidant supplementation and laser treatment can retard loss of vision up to 25%. Moreover, early recognition of symptoms increases the likelihood of detecting new lesions at a treatable stage. Patients with permanent functional vision loss may benefit from vision rehabilitation programs and assistive devices. Although there are no randomized, controlled trials (RCTs) or case-control studies that directly assess the benefit of these interventions, expert consensus, as reflected in the American Academy of Ophthalmology (AAO) guidelines and prominent textbooks, indicates that these interventions increase independence and quality of life. In summary, there is abundant evidence that appropriate treatment for visual conditions can significantly reduce the overall prevalence of visual disability and improve quality of life in a large proportion of vulnerable elders (VEs). Therefore, these indicators focus on the five major causes of visual disability in elderly people: uncorrected Address correspondence to Catherine H. MacLean, MD, PhD, RAND, 1776 Main Street, Santa Monica, CA 90401. E-mail: maclean@rand.org