Abstract
Purpose
Previous studies showed that older persons with vision loss generally reported low levels of health-related quality of life, although study outcomes with respect to feelings of anxiety and social support were inconsistent. The objective of this study was to examine the impact of low vision on health-related quality of life, including feelings of anxiety and social support, among community-living older adults seeking vision rehabilitation services.
Methods
Differences of activities of daily living (Groningen Activity Restriction Scale—GARS), symptoms of depression and feelings of anxiety (Hospital Anxiety and Depression Scales—HADS) and social support (Social Support Scale Interactions—SSL12-I) between 148 older persons ≥57 years with low vision and a reference population (N = 4,792) including eight patient groups with different chronic conditions were tested with Student’s t tests.
Results
Older persons with vision loss reported poorer levels of functioning with respect to activities of daily living, symptoms of depression and feelings of anxiety as compared to the general older population as well as compared to older patients with different chronic conditions. In contrast, older persons with vision loss reported higher levels of social support.
Conclusions
Vision loss has a substantial impact on activities of daily living, symptoms of depression and feelings of anxiety. Professionals working at vision rehabilitation services may improve their quality of care as they take such information into account in their intervention work.
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Introduction
Low vision in old age is prevalent, and due to demographic changes, the prevalence will increase substantially in the future [1–3]. In the Netherlands, the prevalence of low vision among persons 50 years of age and older was estimated 3.3% in 2008 but will increase by 18% in 2020 [2]. Low vision is associated with negative outcomes such as limitations in activities of daily living [4–7], physical dysfunctioning [8], depressive symptoms [5, 6, 9–13] and lower health-related quality of life [7, 14–18]. However, previous studies yielded mixed results regarding feelings of anxiety [9, 11] and social support interactions [4, 6, 10, 19].
Far most studies analyzed only associations between severity of vision impairment and daily functioning in (older) persons with vision loss. And although some studies examined the impact of low vision by comparing older adults with and without vision impairment [4, 7–9, 11, 14, 16, 17], only a very few compared older persons with low vision with older persons with other chronic conditions in order to study its relative impact on the aspects of daily functioning [7, 17]. Both types of knowledge may help to estimate the impact of low vision on daily functioning in older adults, however. Professionals working at vision rehabilitation services may improve their quality of care as they can take into account such information in their intervention work.
We had two aims for the present study. First, to compare the levels of health-related quality of life (i.e., activities of daily living, symptoms of depression, feelings of anxiety and social support) of older people with vision loss seeking vision rehabilitation services with a reference group of older people from the general population. And second, to compare the levels of health-related quality of life of older people with vision loss with older people with different chronic conditions.
Method
Study group
The study group was recruited as part of a randomized controlled trial to evaluate orientation and mobility training by the two main (not-for-profit) organizations for low vision care in the Netherlands: ‘Bartiméus’ and ‘Royal Dutch Visio’ (http://www.visio.org/home). Details of the recruitment strategy were published elsewhere [20, 21]. The initial study sample consisted of 149 adults ≥55 years of age who lived independently or in a home for older people, applied for low-vision rehabilitation services (either by themselves or referred by other health care professionals) and were screened as potentially qualified for mobility training in the use of an identification cane. The latter was performed during an intake conversation by mobility experts of the rehabilitation centre and implies that the client has sufficient remaining vision to see, for instance, large obstacles but may have difficulty recognizing acquaintances. For reasons of comparison with the reference group (persons ≥57 years of age), we excluded one person of 55 years, resulting in a study group of 148 persons of ≥57 years. Persons with cognitive impairment were excluded in both study samples [21, 22].
The Medical Ethical Committee of Maastricht University/Academic Medical Hospital Maastricht granted approval for conducting this study and the research adhered to the tenets of the Helsinki Declaration.
Measures
Data were collected by telephone interviews between January 2008 and January 2010. The interviews included questions about socio-demographics, such as age, gender, educational level and living arrangements.
Health-related quality of life was measured in three domains. First, activities of daily living (ADLs) were assessed with the Groningen Activity Restriction Scale (GARS [23]). The scale consists of 11 items. Scale scores theoretically range from 11 to 44 with higher scores indicating more restrictions in ADL, i.e., poorer functioning.
Second, psychological distress was assessed with the 14-item Hospital Anxiety and Depression Scale (HADS) that was validated in Dutch older persons [24, 25]. The scale consists of two 7-item subscales for symptoms of anxiety and depression, respectively. Total scores theoretically range from 0 to 42 for the full scale and from 0 to 21 for each subscale. Higher scores indicate higher levels of psychological distress.
Finally, social support interactions were measured with the Social Support Scale Interactions (SSL12-I) that was validated in older persons [26]. The scale comprises 3 subscales: ‘everyday social support’ (4 items: referring to social companionship and daily emotional support), ‘support in problem situations’ (4 items: referring to instrumental support, informative support and emotional support in times of trouble), and ‘esteem support’ (4 items: referring to support resulting in self-esteem and approval). Total scores theoretically range from 12 to 48 for the full scale and from 4 to 12 for each subscale. Higher scores indicate more social support.
Analyses
After computing summary scores for the health-related quality of life variables, we compared the mean scores and standard deviations of these variables with reference outcomes of the baseline assessment of the Groningen Longitudinal Aging Study (GLAS [22, 27]). GLAS—conducted between 1993 and 2001—is a Dutch population-based prospective follow-up study of determinants of health-related quality of life in persons ≥57 years of age. For the present study, we included baseline data collected with the previously described instruments from 4,792 persons (see [22]).
First, we compared the scores of the low-vision study group (N = 148) with the GLAS reference population (N = 4,792) and according to three age groups, i.e., 57–74, 75–84 and ≥85 years. Next, we compared the mean scores and standard deviations of the study group with those of eight groups with specific chronic conditions from GLAS: asthma/chronic bronchitis, heart condition, hypertension, diabetes mellitus, back problems, rheumatoid arthritis/other joint complaints, migraine/chronic headache and dermatological disorders [22]. Only “active” conditions were included (i.e., conditions for which a physician was consulted or medicines were used in the 12 months prior to the interview [22]). Differences were tested with Student’s t-test. Data were analyzed with PASW version 17.0 and GraphPad Prism [28].
Results
Study group
Socio-demographic characteristics of the low-vision group are described in Table 1. (Self-reported) duration of low vision was on average 18 years and varied from 1 to 82 years.
Table 2 presents the mean scores and standard deviations of the measures for the full study and reference groups, as well as according to the three age groups. The low-vision study sample reported poorer functioning regarding ADLs and psychological distress. However, levels of social support interactions were higher for the low-vision study group. Generally, differences were largest for the younger participants and smallest for the older participants.
Table 3 shows the outcomes of the comparison of the low-vision sample with the patients with different chronic conditions. Participants from the low-vision sample reported the poorest levels of functioning regarding ADLs and psychological distress except for feelings of anxiety for patients with back pain and for patients with migraine/chronic headache. However, the differences for the latter two groups were not significant. In contrast, the levels of social support interactions were significantly highest for the participants in the low-vision study group.
Discussion
In this study, we examined the impact of low vision on health-related quality of life among older adults seeking vision rehabilitation services. We found that older persons with vision loss generally reported poorer levels of functioning with respect to ADLs, symptoms of depression and feelings of anxiety as compared to the general older population, as well as compared to older patients with different chronic conditions. In contrast, older persons with vision loss reported more social support in all domains. Particularly levels of support in problem situations were higher among people with low vision compared to the general population. A reasonable explanation could be that low-vision problems and associated physical and mental health problems may provoke the needed social interactions and other kinds of support by particularly this group. Previous studies supported our findings with respect to ADLs and symptoms of depression (see Introduction) but showed inconsistent results with respect to both feelings of anxiety and social support interactions [4, 6, 9–11, 19].
Post hoc analyses showed that, although measured slightly different, low-vision patients with a heart condition (N = 50), rheumatoid arthritis/back problems/osteoporosis (N = 43), COPD/asthma/emphysema (N = 27) or diabetes mellitus (N = 24) reported higher GARS and HADS scores compared to the patients of the GLAS reference population indicating poorer levels of functioning. However, the differences for diabetes mellitus were not significant (P > .05) likely due to the limited number of these patients in the study group. The SSL12-I total scores were also higher for these low-vision patient groups although the differences for heart conditions and COPD/asthma/emphysema patients were not significant. This supports our finding that low vision has a negative impact on physical and mental functioning, even irrespective of chronic conditions.
Our study has several limitations. First, although outcomes in the low-vision study group and reference population were measured with the same instruments, differences may exist in characteristics of both samples. However, mean age (77.4 years, SD 8.8 in study group and 77.1 years, SD 8.2 in reference population—not significant) and sex distribution (56.8% women in study group and 56.4% women in reference population—not significant) were similar in both groups. Second, chronic conditions were self-reported. To reduce report bias, only conditions for which a physician was consulted or medicines were used in the 12 months prior to the interview were included in both samples. Finally, the mode of administration of the GARS, HADS and SSL 12-I was slightly different in both settings: in the low-vision sample, all measures were assessed with telephone interviews while in GLAS the GARS was assessed in a face-to-face interview and the HADS and SSL 12-I were assessed with a questionnaire during this interview.
We conclude that vision loss has a negative impact on ADLs, symptoms of depression and feelings of anxiety in older people. However, social support was highest in the low-vision sample. Professionals working at vision rehabilitation services may improve their quality of care as they take such information into account in their intervention work.
Abbreviations
- ADL:
-
Activities of daily living
- GARS:
-
Groningen activity restriction scale
- GLAS:
-
Groningen longitudinal aging study
- HADS:
-
Hospital anxiety and depression scale
- HADS-D:
-
Hospital anxiety and depression scale—depression subscale
- HADS-A:
-
Hospital anxiety and depression scale—anxiety subscale
- SSL12-I:
-
Social support list 12-interactions
References
Massow, R. W. (2002). A model for the prevalence and incidence of low vision and blindness among adults in the US. Optometry and Vision Science, 79, 31–38.
Limburg, H., & Keunen, J. E. E. (2009). Blindness and low vision in The Netherlands from 2000 to 2020: Modeling as a tool for focused intervention. Ophthalmic Epidemiology, 16, 362–369.
World Health Organization. (2011). Visual impairment and blindness. Fact sheet no 282. Updated April 2011. http://www.who.int/mediacentre/factsheets/fs282/en/. Accessed June 21, 2011.
Alma, M. A., Van der Mei, A. F., Melis-Dankers, B. J. M., Van Tilburg, T. G., Groothoff, J. W., & Suurmeijer, T. H. P. B. M. (2011). Participation of the elderly after vision loss. Disability and Rehabilitation, 33, 63–72.
Kempen, G. I. J. M., Verbrugge, L. M., Merrill, S. S., & Ormel, J. (1998). The impact of multiple impairments on disability in community-dwelling older persons. Age and Ageing, 27, 595–604.
Wallhagen, M. I., Strawbridge, W. J., Shema, S. J., Kurata, J., & Kaplan, G. A. (2001). Comparative impact of hearing and vision impairment on subsequent functioning. Journal of the American Geriatrics Society, 49, 1086–1092.
Williams, R. A., Brody, B. L., Thomas, R. G., Kaplan, R. M., & Brown, S. I. (1998). The psychosocial impact of macular degeneration. Archives of Ophthalmology, 116, 514–520.
Scott, I. U., Smiddy, W. E., Schiffman, J., Feuer, W. J., & Pappas, C. J. (1999). Quality of life of low-vision patients and the impact of low-vision services. American Journal of Ophthalmology, 128, 54–62.
Augustin, A., Sahel, J. A., Bandello, F., Dardennes, R., Maurel, F., Negrini, C., et al. (2007). Anxiety and depression prevalence rates in age-related macular degeneration. Investigative Ophthalmology & Visual Science, 48, 1498–1503.
Burmedi, D., Becker, S., Heyl, V., Wahl, H. W., & Himmelsbach, I. (2002). Emotional and social consequences of age-related low vision: A narrative review. Visual Impairment Research, 4, 47–71.
Evans, J. R., Fletcher, A. E., & Wormald, R. P. L. (2007). Depression and anxiety in visually impaired older people. Ophthalmology, 114, 283–288.
Hayman, K. J., Kerse, N. M., La Grow, S. J., Wouldes, T., Robertson, M. C., & Campbell, A. J. (2007). Depression in older people: Visual impairment and subjective ratings of health. Optometry and Vision Science, 84, 1024–1030.
Horowitz, A., Reinhardt, J. P., & Kennedy, G. J. (2005). Major and subthreshold depression among older adults seeking vision rehabilitation services. American Journal of Geriatric Psychiatry, 13, 180–187.
Chia, E. M., Wang, J. J., Rochtchina, E., Smith, W., Cumming, R. R., & Mitchel, P. (2004). Impact of bilateral visual impairment on health-related quality of life: The Blue Mountains eye study. Investigative Ophthalmology & Visual Science, 48, 1498–1503.
Lamoureux, E. L., Fenwick, E., Moore, K., Klaic, M., Borschmann, K., & Hill, K. (2009). Impact of the severity of distance and near-vision impairment on depression and vision-specific quality of life in older people living in residential care. Investigative Ophthalmology & Visual Science, 50, 4103–4109.
La Grow, S., Alpass, F., Stephens, C., & Towers, A. (2011). Factors affecting perceived quality of life of older persons with self-reported disability. Quality of Life Research, 20, 407–413.
Langelaan, M., de Boer, M. R., Van Nispen, R. M. A., Wouters, B., Moll, A. C., & Van Rens, G. H. M. B. (2007). Impact of visual impairment on quality of life: A comparison with quality of life in the general population and with other chronic conditions. Ophthalmic Epidemiology, 14, 119–126.
McKean-Cowden, R., Varma, R., Wu, J., Hays, R. D., & Azen, S. P. (2007). Severity of visual field loss and health-related quality of life. American Journal of Ophthalmology, 143, 1013–1023.
Wang, C. W., Chan, C. L. W., Ho, A. H. Y., & Xiong, Z. (2008). Social networks and health-related quality of life among Chinese older adults with vision impairment. Journal of Aging and Health, 20, 804–823.
Ballemans, J., Zijlstra, G. A. R., Van Rens, G. H. M. B., Schouten, J. S. A. G., & Kempen, G. I. J. M. (submitted, available upon request). Usefulness and acceptability of a standardised orientation and mobility training for partially-sighted older adults using an identification cane.
Zijlstra, G. A. R., Van Rens, G. H. M. B., Scherder, E. J. A., Brouwer, D. M., Van der Velde, J., Verstraten, P. F. J., et al. (2009). Effects and feasibility of a standardised orientation and mobility training in using an identification cane for older adults with low vision: Design of a randomised trial. BMC Health Services Research, 9, 153.
Kempen, G. I. J. M., Ormel, J., Brilman, E. I., & Relyveld, J. (1997). Adaptive responses among Dutch elderly: The impact of eight chronic conditions on health-related quality of life. American Journal of Public Health, 87, 38–44.
Kempen, G. I. J. M., Miedema, I., Ormel, J., & Molenaar, W. (1996). The assessment of disability with the Groningen activity restriction scale. Conceptual framework and psychometric properties. Social Science and Medicine, 43, 1601–1610.
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361–370.
Spinhoven, P. H., Ormel, J., Sloekers, P. P. A., Kempen, G. I. J. M., Speckens, A. E. M., & Van Hemert, A. M. (1997). A validation study of the hospital anxiety and depression scale (HADS) in different groups of Dutch subjects. Psychological Medicine, 27, 363–370.
Kempen, G. I. J. M., & Van Eijk, L. M. (1995). The psychometric properties of the SSL12-I: A short scale for measuring social support in the elderly. Social Indicators Research, 35, 303–312.
Kempen, G. I. J. M., Brilman, E. I., & Ormel, J. (1998). Groningen longitudinal aging study. Een onderzoek naar het dagelijks functioneren, het welbevinden en de zorgbehoefte van ouderen. Tijdschrift voor Gerontologie en Geriatrie, 29, 141–149. (in Dutch).
Motulsky, H. J. (1999). Analyzing data with GraphPad prism. San Diego, CA: GraphPad Software.
Acknowledgments
We thank the collaborating organizations for low vision care in the Netherlands, i.e., Bartiméus and Royal Dutch Visio, and their clients, orientation and mobility trainers and contact persons, particularly D. M. Brouwer, N. van der Meent, J. van der Velde and P. F. J. Verstraten. The Centre for Data and Information Management of Maastricht University (MEMIC) and B. Franssen and R. Handels are acknowledged for assistance in the data collection. This study was funded by ZonMw—the Netherlands Organization for Health Research and Development, Program In Sight (grant 94305004).
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Open Access This is an open access article distributed under the terms of the Creative Commons Attribution Noncommercial License (https://creativecommons.org/licenses/by-nc/2.0), which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
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Kempen, G.I.J.M., Ballemans, J., Ranchor, A.V. et al. The impact of low vision on activities of daily living, symptoms of depression, feelings of anxiety and social support in community-living older adults seeking vision rehabilitation services. Qual Life Res 21, 1405–1411 (2012). https://doi.org/10.1007/s11136-011-0061-y
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DOI: https://doi.org/10.1007/s11136-011-0061-y