William A Monaco OD MSEd PhD University of South Florida John E Crews DPA 1 Chronology of the Problem and How I Became Interested Origin serendipitously in the year 2000 I began exploring the need for nursing home eye care in Washington DC by contacting local nursing homes ID: 916406
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Eye Disease and Vision Loss Among Nursing Home Residents Aged 65 Years and Older: The Delaware Study
William A. Monaco, OD, MSEd, PhD
University of South Florida
John E. Crews, DPA
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Slide2Chronology of the Problem and How I Became InterestedOrigin serendipitously in the year 2000I began exploring the need for nursing home eye care in Washington, D.C. – by contacting local nursing homes.Within 7 months I was serving 23 facilities, the process and the experience was repeated when I relocated to Delaware – there simply were no eye care providers in nursing homes on a scheduled basis.In a short period of providing eye care, it was apparent that there was a huge endemic problem and disconnect for eye care for these patients that was going unmet.
This presentation will discuss how I approached the problem in a manner that has resulted in a huge data set that will benefit these residents, if it is embraced by skilled care and assisted living facilities.First, I will discuss the problem, then the impact of good comprehensive eye care and finally a potential solution.
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Slide3Population growth in 2000 years
At the time of the birth of Christ the population of the world was about 300 million.
By the 19th century it had increased to 1 BillionIn the first decade of the 21st Century it increased to 7 BillionBy 2020 it had reached 8 BillionThe population increased by approximately 1 Billion in 20 years3
Slide4How will this new age distribution effect society?
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Slide5Demographics and the “age quake” or “graying of the world”
Population of 60 and older will drive social and economic systems.
Since the last years of life are associated with increased disability and sickness, this will put enormous demands on social and health services and drive the costs for care up. These changes will limit the abilities of health, social and political infrastructure to deal with the magnitude of the problem – this will occur in developed and developing countries.5
Slide610 Most Common Conditions Suffered by Nursing Home Residents- and Number of Chronic Conditions
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Slide7U.S. Population Age 65 and Older & Nursing HomesU.S. Population 65 years and older2010: 1.4 million occupied beds (3%) from a population of 40.2 million.By 2050: population increases to 88.5 million, of which 6.2 million (7%) will need long term care.Approximately 60% of nursing home residents survive 30 months (range 1-5 years).Vision/eye health/eye disease is not counted as a Chronic Condition
Slide8Prevalence of Vision impairment BY AGE, RACE AND GENDER IN THE U.S. at the time of our study (2010)
NIH defines Vision impairment at ≤ 20/40 but not worse than 20/200
These data from NEI represent an age-matched cohort of ambulatory patients conforms with study period.For the mean age of a nursing home resident (82 y.o.) the values by race are 11%, 15% and 17% respectively for white, black and Hispanic races.8
Slide9PREVALENCE RATES OF BLINDNESS BY AGE, RACE AND GENDER IN THE U.S. (2010)
NEI Defines blindness as The best-corrected visual acuity of 20/200 or worse in the better-seeing eye.
For this age-matched cohort at 80+ the values are 9%, 7% and 2% for white, black and Hispanic races.9
Slide10Co-Morbidities go Hand-in-Hand with Vision Loss
Let’s investigate why the “VISION” exam is important in patients with comorbidities.
It is possible to “cure” blindness by simply prescribing glasses to a resident who has poor vision and bring the acuity into a normal functional range – easy!
What is poorly understood is that the primary reason for an “Eye Exam is NOT OPTICAL”, it is to rule out blinding eye diseases that have no signs or symptoms.
The eye is the “window to the body” – systemic conditions like diabetes, hypertension, kidney disease and many others, including neurological conditions like “brain tumors” can be diagnosed, sometimes before there are clinical signs.
NOTE: A complete comprehensive exam can be done on ANY patient without them saying a WORD so patients that suffer dementia should not be excluded nor patients who are intubated – Here I will share a couple of examples of how this worked dramatically for my patient’s
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Slide11What is the impact on Quality of Life?
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Slide12NURSING HOMES IN THE U.S. 12
Slide13What is the impact of vision loss on U.S. citizens 40 years and older
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Slide14The Disconnect
Knowledge about older people living in the community continues to be refined, the vision and eye health status of people residing in nursing homes remains fragmented, incomplete, and neglected.
Vision concerns are often not addressed, and data regarding vision are not collected or reported in a systematic manner.
People residing in nursing homes often have substantial cognitive limitations that competes with efforts to address vision.
Most importantly:
Vision loss is not an obvious disability, and vision problems may go underestimated, undetected, or ignored, and the progression of eye problems may be overlooked.
The contribution of vision impairment to falls, and visual limitations caused by stroke may not be recognized.
The overall result, we suspect, is that vision loss and blindness among nursing home residents requires additional understanding.
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Slide15What has clinical research contributed?
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Slide16What do we know about Surveillance
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Slide17Nursing Home Studies in the US
N
CataractGlaucomaMDDRVIBlindKonrzweig (1957)100061%5.3%29.3%NANLP=13.9%NAWhitmore (1989)22581%NA37%2.1%44%30%Wingert (1992)4783%6%17%NANANATielsch (1995)499NANANANA18.8%17%Eichenbaum (1999)73282.5%41.4%70.7%1.7%NANAKeller (2001)13451%11%17%3%46%15%West (2003)1305NA
NANANA38%NAVoytas (2004)160NA40%NANANA
NA
Friedman (2004)
1307
NA
NA
NA
NA
37%
NA
Owsley (2007)
380
32.5%
8.2%
4.6%
3.1%
57%
10%
Andersson (2020)
1856
NA
NA
NA
NA
67%
8.7%
Larsen (2018)
600
NA
NA
NA
NA
24%
5%
Slide18Were historical clinical trials sufficient to impact policy?
National attempts to promote vision and eye health among institutionalized residents have largely been unsuccessful.
Resolutions proposed by the American Public Health Association in 1992 and 1997 as well as the 2016 National Academies of Sciences, Engineering, and Medicine report, resulted in little progress to document the clinical characteristics, functional capacity, and impact of vision loss on the lives of nursing home residents.
There have been isolated cases where skilled care facilities established protocol or commitment for eye care services nationwide.
The Impact
Most vision problems are amenable to correction, improvement, or remediation
Interventions that could substantially improve the quality of life and functioning of people living in nursing homes.
Early detection and treatment of age-related eye diseases and appropriate refractive corrections represent essential first steps in identifying key factors potentially linking vision loss with cognitive decline, frailty, and falls--all critical to care planning and resident centered care
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Slide19The value of the clinical factors assessed
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Slide20Study purpose-The historical inconsistencies in data collection and methods led us on this path:
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Slide21Characteristics of Population in Delaware Study
Normal Vision
(n=731)Impaired Vision(n=997)Blind(n=291)Mean Age81.482.284.2Male41.7%35.8%34.7%Female 58.3%64.2%65.3%White76.9%74.8%74.6%Black20.9%22.6%22.3%Other 2.2%2.6%3.1%Diabetes34.2%
37.6%37.5%
Slide22Eye Diseases Diagnosed in Sample Population in Delaware Study
Normal Vision
Impaired VisionBlind Cataract52.3%64.9%62.2%Macular Degeneration20.8%23.4%38.5%Glaucoma21.5%26.0%40.2%Diabetic Retinopathy6.7%7.1%12.0%
Slide23Visual Function by Age and Diagnosed Eye Disease
Vision Impairment & Blind
Blind65-74 Years61.4%11.5%75-84 Years61.1%12.5%85-94 Years65.1%16.4%95-104 Years 81.7%25.0%Cataract68.415.0Macular Degeneration69.422.5Glaucoma70.522.0Diabetic Retinopathy 68.422.6
Slide24Confirmation with Reviewer Comments
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Slide25Epipheny
We have learned from working in this special environment – we can make a difference that is not limited to vision improvement – systemic, cognitive, safety, ADL’s, QofL
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Slide26Public health impact
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Slide27Specific Clinical Examples of ARED’s
Cataract
GlaucomaMacular DegenerationDiabetic Retinopathy27
Slide28End Stage?
The Impact of no care might best be reflected with some of these examples28
Slide29Patient SB
57
y.o
., Male, African American
Nuclear Sclerotic Cataract
HTN and Diabetes
CAD
End Stage Kidney Disease
Double Amputee – ATK (RT), BTK (LFT)
Social: No Drugs/ETOH; Tobacco Use
Cognitive: PARANOID SCHIZOPHRENIA
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Slide30SB Ocular Findings
Proliferative Diabetic Retinopathy-laser treatment
Clinically Significant Macular EdemaCT scaffolding and scaring into the vitreous30
Slide31JM Ocular Findings
Glaucomatous Cupping
Hypertensive and Diabetic Retinopathy with PRP31
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Slide33Conclusions33
Slide34Thank you!34