The Elder's Right to Sight Collaborative: A new model of eye care delivery for the elderly

Article Outline

• Abstract
• The project
• Results
• Discussion
• Conclusion
• References
• Copyright

Abstract 

Vision and visual impairment have a significant impact on older adults' daily function and safety within their homes and communities. Yet many do not seek out the necessary care to address their visual health. Many older adults want to age in places that require a supportive environment to compensate for changes in abilities and to promote healthy aging and quality of life. The Elder's Right to Sight Collaborative (ERTS) was established to gain insight into the role of the environment in maintaining the functional independence and safety of older adults with visual impairment and to understand the barriers to obtaining the necessary eye care services. The ERTS provides education, screening, environmental assessments, and simple tools to complete daily activities. The screening results indicate significant need for eye care services to this population. However, service delivery needs to be flexible to meet the needs of this population. A team approach to address education, eye care services, rehabilitation, environmental assessment, and social services is needed. Through education, accessible services, rehabilitation, and environmental modifications, a significant impact on an older adult's independence and quality of life can be attained.

Keywords: Visual impairment, Access to care, Prevention, Geriatrics

Our population is aging, and it has been estimated that by 2030 there will be 70 million individuals 65 and older; this will make up 20% of the U.S. population.¹ Normative aging changes, disease processes commonly associated with aging, and an increased desire of older adults to age in place (to stay where they live) creates unique implications for the health care and housing industries.² Elders are the fastest-growing and most vulnerable population for sight loss. Four of the 5 major causes of blindness are directly related to the aging process: age-related macular degeneration (AMD), diabetic retinopathy, glaucoma, and cataracts.³ There are an estimated 14 million Americans with serious sight loss who may not be eligible for services because they are not “legally blind” (best-corrected visual acuity of 20/200 or worse or visual field of less than 20 degrees).⁴ Nonetheless, their vision impairment is significant and can have an effect on independence and the ability to live safely in their homes. In addition, health and housing issues of elders are often interrelated and yet forgotten. Health concerns can create and compound housing concerns and vice versa.²

Despite the impact of visual impairment on the daily lives of the elderly, many do not seek medical resources to correct their visual loss or seek home modifications to deal with difficulties they face in their homes.⁵ The elderly are frequently unaware of their vision problems or do not seek help and subsequently do not see the impact it has on their daily lives. Health care providers, elders themselves, and caregivers, frequently equate loss of visual function to old age, and thus consider it to not be amenable to treatment. Many people assume nothing can be done to improve the quality of life in elders with irreversible vision loss. The Lighthouse Survey on Vision Loss found that 43% of the elderly were unaware of the availability of vision rehabilitation services.⁶

Today there is a new emphasis being placed on wellness and prevention and management of chronic illness and a growing awareness of the impact of community on health status; yet, access and delivery of services has not adapted efficiently to this paradigm shift. Lawler² found that in the last decade there has been an increased desire of older adults to remain in their current residence. Successful aging in place requires coordination of housing and health care services that are geared to the individual's changing needs in that current environment. These systems must become more integrated to provide optimal services to the older adult. Lawler states, “aging in place with appropriate care and supportive services is not only the most desirable way of aging, but can also be a more effective and efficient method. The connections between housing and health concerns must be examined to begin to develop strategies to address this unmet need and growing demand of the older adult and his or her changing needs.”²

Although many older adults want to remain in their homes with the goal of successfully aging in place, they become more dependent on their environment to compensate for changes in their mobility, such as holding on to furniture or railings because of gait instability. Creating a safe and supportive environment can promote healthy aging and improve quality of life. Simple environmental changes such as increased lighting can improve an older adult's ability to safely identify hazards, help to perform daily activities such as food preparation, and to continue to participate in leisure pursuits such as reading or needlework.

Visual impairment including decreased visual acuity, loss in visual field, and low contrast sensitivity has been linked to disability,⁷ falls,⁸ difficulty in mobility,⁹ difficulty in climbing stairs,¹⁰ difficulty driving,⁵ restriction in activities of daily living,¹¹ social isolation,¹² loss of independence,¹¹, ¹³ depression,¹¹ suicide,¹³ and mortality.¹⁴ Much has been done in terms of identification of the problem, but little has been done in terms of intervention.

Back to Article Outline

The project 

The effect that visual impairment has on daily function has been researched thoroughly. However, this body of literature lacks research examining aspects of intervention. Some unanswered questions remain, such as: What is the role of the environment in terms of maintaining the functional independence and quality of life of older adults with visual impairment? What are the challenges facing public housing in terms of addressing the needs of this growing population? Is there a public responsibility in terms of addressing these needs? Are there adequate intervention models to address the visual health of this population? Many states are attempting to reform home care and increase services and reimbursement to create a better system to support older adults who wish to “age in place.”² Based on the literature and clinical observations of the lack of vision services to the older adult population in public housing, the idea for the Elder's Right to Sight project was formed. The Elder's Right to Sight Collaborative (ERTS) set out to address the above questions to create a sustainable model of eye care for older adults.

The ERTS's mission statement is “to improve the visual function of seniors through prevention, education, access, environmental modification, and service delivery. Our goal is to improve the quality of life, health, and well-being of elders in senior housing through a holistic approach to eye care.” The ERTS focuses on providing services to older adults “aging in place” in public housing facilities in the Boston area. This population was targeted because of lack of services currently provided to older adults residing in public housing. Using a collaborative approach, the founders of the Elder's Right to Sight project (an optometrist and an occupational therapist), along with public housing and local social service agencies, discussed the creation of a community-based intervention targeting residents of public elderly housing in the metro Boston area. A collaboration developed among the New England Eye Institute, Boston Housing Authority, Massachusetts Housing, MAB Community Services, and Boston University. Potential funding agencies, as well as social service agencies, public health officials, home care agencies, and other interested parties, were invited to a “Consensus Conference.” The theme of the conference focused on the needs of older adults and issues of access to services.

The next step was to gather the information about each housing site needed to apply for grant funding. ERTS met with state and federal housing entities for initial approval to provide services within public housing. To increase “buy in,” the ERTS established relationships with each building's Resident Service Coordinators (RSC), individuals who are primarily social workers employed by the housing authority to manage the day-to-day issues of older adult residents. They provided ERTS information on the culture of each building, including language barriers, demographics, and current services and resources available (or unavailable) at each site.

After communicating with private and nonprofit funding agencies and the resident service coordinators, the ERTS received funding for the project. The project began by holding “Community Vision Seminars” at low-income housing sites. These seminars were an invaluable opportunity to open communication with residents of the public housing sites and were considered an integral piece of the ERTS project. An optometrist (OD), an occupational therapist (OT), and occasionally OD or OT students led the seminars. Although each seminar was individualized to the needs of the building, the following components were typically addressed:

The Community Vision Seminars generally lasted from 1 to 2 hours, and participants were encouraged throughout to ask questions.

The VFRA, created by the New England Eye Institute, is a vision screening tool consisting of distance and near visual acuity, contrast sensitivity, and an Amsler grid screening. It also includes an interview component including questions related to medical and ocular health, falls, last eye examination, and age of glasses. This screening provides a general picture of the visual status of each older adult, an assessment of functional complaints, and a history of their visual health. The ERTS also used the VFRA to gather quantitative data about the visual status of each participant and eye care services they were currently receiving. After administration of the VFRA, a referral was made to the older adult's regular eye care practitioner if further eye care services were needed. If the older adult did not have an eye care practitioner, a provider was recommended or services were provided through the ERTS in his or her residence.

The environmental assessment of individual apartments enabled the ERTS to examine older adults' daily functions in their own home environment. Lighting measurements (in lux) were taken in each room and at the participant's “reading area.” Task lighting was also noted as was the accessibility of the apartment. The environmental assessment yielded simple recommendations that could enhance each older adult's functional independence. Common recommendations made to individuals included reducing clutter, changing the placement of lights, using sheer curtains to cut down glare, and using task lights when reading or engaging in fine motor tasks.

Back to Article Outline

Results 

From 2004 to 2006, the ERTS collaborative provided educational programs at 36 different sites in the greater Boston area. Ten sites were urban settings, and the others were located in the suburbs of Boston. Although potentially 3,115 older adult residents had the opportunity to attend, only 1,377 (44%) participated in the ERTS's community vision seminars. A handful of these individuals attended multiple times, as the ERTS revisited many of the buildings on several occasions. Three hundred fifty-two (16%) attendees participated in the visual function risk assessment, and several older adults asked questions about visual health-related topics.

Of the 352 older adults, we assessed using the VFRA, 221 (63%) failed the assessment and were counseled to see an optometrist or ophthalmologist for a comprehensive evaluation of their visual health. Twenty-one of these older adults chose to follow-up the results with their own eye care provider, and the remaining 200 individuals requested further evaluation at the New England Eye Institute. Twenty-six (13%) older adults who requested further evaluation at the New England Eye Institute followed through with their appointments. The remainder could not get to appointments outside their building, refused to be transported by elder-friendly public transit, or simply declined a follow-up appointment. The ERTS offered home eye care services, but many residents did not keep their appointments or stated they believed their decline in vision was a natural part of aging.

Using the VFRA, the ERTS assessed 268 (76%) women and 84 (24%) men with an average age of 77.75 years. The average distance visual acuity was 20/113 in the right eye (O.D.) and 20/143 in the left eye (O.S.) and the mean near visual acuity was 20/113 O.D. and 20/132 O.S. (see Figure 1). Participants reported an average time of 32 months since their most recent eye care appointment. (The American Optometric Association recommends that older adults see their eye care provider at least once every 1 to 2 years.¹⁵) Of the 291 people who wore glasses, the average age of their spectacles was 30.35 months. In addition, 21 older adults reported having age-related macular degeneration, 33 reported glaucoma, 136 reported cataracts, 114 reported cataract surgery, 156 reported hypertension, 75 reported diabetes, and 107 reported falling in the last 5 years. Many of the older adults were quick to state that their fall was unrelated to their vision (see Table 1).

• 
  • View Large Image
  • Download to PowerPoint

• Figure 1. 

  The distribution, by percentage, of distance and near visual acuity by right and left eye (n = 352).

Table 1. Summary of visual function risk assessment (n = 352)

VA, Visual acuity; DX, diagnosis.

Note: 221 residents (63%) failed screening and required follow-up; 21 will go to their own eye doctor; 18 require low vision rehabilitation services.

Environmental assessments were completed for 36 apartments. The Illuminating Engineering Society of North America (IESNA) recommends a minimum ambient illumination of 300 lux for all rooms within a home and 750 lux for task lighting for reading tasks.¹⁶ The result of the lighting measurements for each room in the individual apartments was (on averages) 57.62 lux in entrance way; 196.9 lux in living room; 130.8 lux in bathroom; 90.98 lux in bedroom; and 393.17 lux in kitchen. Compared with IESNA guidelines, these older adults currently live with lighting conditions significantly below recommended levels (see Table 2, Table 3).

Table 2. Summary of lighting averages (n = 36)

Table 3. Summary of environmental assessments (n = 36)

Back to Article Outline

Discussion 

The ERTS pilot project found varying degrees of participation at each building. Yet, conversations with resident service coordinators at each housing site found that many elders who would benefit from education and services do not seek out or assert access to these resources. This lack of access may be attributed to the varying degree of social capital in each building. Social capital has been defined broadly as the resources available to individuals and groups through their social connections to their communities.¹⁷

Social capital is very important to successful aging because older adults are at greater risk for losing critical parts of their social ties as they age, thereby making them more dependent on the social capital available within their communities.¹⁸ Many seniors have lived in public housing for varying periods of time and therefore have varying levels of social connectedness to their community. The subculture of the building in which elders live plays a vital role in their health. Therefore, this subculture needs to be assessed to identify and understand the best ways to engage and motivate older adults to participate in seminars and screenings and access appropriate health care services. Some factors essential to success include identifying the various language groups, determining the best times to hold in-house seminars, and meeting and developing relationships with the leaders of each building's tenant task force to share the goals of the project. Consistent visibility within the housing sites has also supported the residents' ability to ask questions about their current visual health and gain knowledge about eye conditions, treatment, and preventative care for eye diseases. Housing is multidimensional, and each building's distinct character is influenced by a myriad of factors, including the residents, the staff, the greater community in which it is situated, the design of the common areas, the social networks of the residents, and the social capital that has been built up over the years.

Senior housing is an ideal portal to deliver services because there is a natural community in which a direct impact can occur by developing trust and demonstrating how visual impairments affect daily life. Through integrated eye care services, education, and lighting and contrast modifications, the ERTS strives to create a more supportive environment for older adults by optimizing their visual functioning during daily life tasks. Education is not only focused on discussion about disease, but is also complemented by simple, practical, and cost-effective changes older adults can make to enhance their living environments.

Environmental intervention is a key element of any effort to improve visual health and quality of life of older adults. From the results of this project, the ERTS discovered that the apartments were more problematic than anticipated. A large majority of seniors in low-income housing have nonideal lighting situations, fixtures that create glare sources, light bulbs that are burnt and not replaced, or lights that emit a low amount of illuminance, which all negatively contribute to the function and quality of life of older adults. In addition, contrast is poor, especially in the bathroom—the room with a high rate of falls—as the bath tub, floor, and grab bars tend to be different shades of white.¹⁹ Light is not strictly a quantitative value, such as intensity of light. Qualitative factors of a proper planning of lighting with good contrast of conditions and absence of glare are also important and contribute to the quality of life.²⁰ With this better understanding of how the environment affects the visual function of so many facets of life in an older adult, there needs to be education for facility managers, seniors, caregivers, government officials, health care providers, and social service agencies, so that such changes can aid older adults in living independently in their homes.

Vision loss is a community problem, not a narrow medical care issue. There is a significant paradigm shift occurring in health care toward an emphasis on wellness and prevention, a focus on the management of chronic illness, and a growing recognition of the influence that the health of the community plays on the health of individuals.²¹ In addition, the health of individuals or groups is less related to medical care (about 10% is the estimate), and much more closely connected to social, economic, and environmental factors in their community.¹⁷ Research implies that good health status is more dependent on quality-of-life factors than on diagnosis and treatment of acute medical conditions.²²

In light of these findings, a significant number of participants in the ERTS pilot project failed the visual function risk assessment, and a more alarming number were unable or unwilling to follow-up because of transportation issues or lack of insurance coverage. Loss of visual function is not equated with old age or vice versa. There are normative changes that occur in the eye with age, but these changes do not necessarily lead to significant functional changes or blindness. On the other hand, older adults have an increased risk of vision loss as a result of age-related eye diseases: AMD, diabetic retinopathy, glaucoma, and cataracts.³ Unfortunately, many people assume nothing can be done to improve the quality of life for older adults with irreversible vision loss.⁶ As discussed above, there are simple strategies and interventions that can make a significant impact on individuals' daily lives. Therefore, better education about normative aging changes and eye disease and strategies to assist those with visual impairment need to be developed to improve the health and well-being of older adults within the community.

Lastly, effective intervention to prevent and treat vision loss requires high degrees of community engagement. Intervention cannot function or be sustained without the synergistic relationships among older adults who live in public housing, public housing agencies, social service agencies, and individual housing facilities. Without collaborative participation from these key groups, change will not be accomplished.

Back to Article Outline

Conclusion 

The ERTS has highlighted the connection between visual health and housing, in particular the disconnection of our current eye care delivery system to the needs of older adults. This project was conducted at public senior housing facilities, but we believe the findings and conclusions translate to all older adults regardless of their social economic status.

The public health system in the United States focuses on prevention, access, and health disparities.²³ However, the health care system has not effectively addressed the importance of these issues in the arena of eye care and older adults. The Centers for Disease Control and Prevention recognized this need and introduced the Visual Health Initiative to develop a coordinated approach for improving the visual health of individuals.²⁴ Still, the disjointed health care system, as well as the inefficiencies of providing care without consideration of older adults' housing or other environmental factors, is also troublesome. To provide holistic care, social services and health care services need to converge in a manner that will be advantageous to older adults.¹¹

Service delivery needs to be multifaceted, creative, comprehensive, easily accessible to older adults, and flexible in its delivery. A comprehensive eye care service delivery model should include education to providers, older adults, and caregivers; primary eye care services; specialty eye care services; low vision rehabilitation; environmental evaluation of the home internally for hazards and lighting; and assessment and recommendations of the external environment to housing agencies and the local government.

A team approach utilizing the expertise of different professionals (optometrists, ophthalmologists, occupational therapists, orientation and mobility teachers, social workers, nurses, geriatricians, case managers, physical therapists, and community organizers) is needed to assure comprehensive, coordinated care. Through continued efforts throughout the metro Boston community, the ERTS is eager to reinforce research suggesting that when visual impairments are addressed—with prevention, access, service, and rehabilitation—individuals benefit significantly, and quality of life is enhanced.¹⁰

Back to Article Outline

References 

1. Desai MM, Zhang P, Hennessy CH. Surveillance for morbidity and mortality among older adults—United States, 1995-1996. MMWR CDC Surveill Summ. 1999;48:7–25
   • View In Article
   • MEDLINE
2. Lawler K. Aging in place: coordinating housing and health care provision for America's growing elderly population [online]. Joint Center for Housing Studies of Harvard University, 2001. Available at: http://www.nw.org/network/pubs/studies/documents/agingInPlace2001.pdf. Last accessed June 11, 2008.
   • View In Article
3. Vision problems in the U.S.: Prevalence of adult vision impairment and age-related eye disease in America [on-line]. National Eye Institute and Prevent Blindness America, 2008. Available at: http://www.preventblindness.org/vpus/2008_update/VPUS_2008_update.pdf. Last accessed June 11, 2008.
   • View In Article
4. Campbell VA, Crews JE, Moriarty DG, et al. Surveillance for sensory impairment, activity limitation, and health-related quality of life among older adults—United States, 1993-1997. MMWR CDC Surveill Summ. 1999;48:131–156
   • View In Article
   • MEDLINE
5. Louie J. Housing modifications for disabled elderly households [on-line]. Joint Center for Housing Studies of Harvard University W99-8, September 1999. Available at: http://www.jchs.harvard.edu/publications/seniors/louie_W98-8.pdf. Last accessed June 11, 2008.
   • View In Article
6. The Lighthouse Inc. The Lighthouse national survey on vision loss: the experience, attitudes and knowledge of middle-aged and older Americans. New York: The Lighthouse, Inc.; 1995;
   • View In Article
7. Ross JE, Bron AJ, Clarke DD. Contrast sensitivity and visual disability in chronic simple glaucoma. Br J Ophthalmol. 1984;68:821–827
   • View In Article
   • MEDLINE
   • CrossRef
8. Ivers RQ, Cumming RJ, Mitchell P, et al. Visual risk factors for hip fracture in older people. J Am Geriatr Soc. 2003;51:356–363
   • View In Article
   • MEDLINE
   • CrossRef
9. Rubin GS, Roche KB, Prasada-Rao P, et al. Visual impairment and disability in older adults. Optom Vis Sci. 1994;71:750–760
   • View In Article
   • MEDLINE
   • CrossRef
10. West SK, Rubin GS, Broman AT, et al. How does visual impairment affect performance on tasks of everyday life? The SEE project. Salisbury eye evaluation. Arch Ophthalmol. 2002;120:774–780
    • View In Article
    • MEDLINE
11. Ramrattan RS, Wolfs RCW, Panda-Jonas S, et al. Prevalence and causes of visual field loss in the elderly and associations with impairment in daily functioning. Arch Ophthalmol. 2001;119:1788–1794
    • View In Article
    • MEDLINE
12. Wang JJ, Mitchell P, Simpson JM, et al. Visual impairment, age-related cataract, and mortality. Arch Ophthalmol. 2001;119:1186–1190
    • View In Article
    • MEDLINE
13. Waern M, Rubenowitz E, Runeson B, et al. Burden of illness and suicide in elderly people: Case-control study. BMJ. 2002;324:1355–1358
    • View In Article
    • CrossRef
14. Taylor HR. Fred Hollows lecture. Eye care for the community. Clin Exp Ophthalmol. 2002;30:151–154
    • View In Article
15. American Optometric Association. (2008). Adult vision: Over 60 years of age. Available at: http://www.aoa.org/x9454.xml. Last accessed July 28, 2008.
    • View In Article
16. Lighting for the aged and partially sighted. Recommended practice for lighting and the visual environment for senior living (RP-28-98). New York: Illuminating Engineering Society of North America. 1999;
    • View In Article
17. Kawachi I, Berkman LF. Social cohesion, social capital, and health. In:  Berkman LF,  Kawachi I editor. Social epidemiology. New York: Oxford University Press; 2000;p. 174–190
    • View In Article
18. Cannuscio C, Block J, Kawachi I. Social capital and successful aging: The role of senior housing. Ann Intern Med. 2003;139:395–399
    • View In Article
19. Stevens M, Holman CD, Bennett N. Preventing falls in older people: Impact of an intervention to reduce environmental hazards in the home. J Am Geriatr Soc. 2001;49:1442–1447
    • View In Article
    • MEDLINE
    • CrossRef
20. Brunnstrom G, Sorensen S, Alsterstad K, et al. Quality of light and quality of life—the effect of lighting adaptation among people with low vision. Ophthal Physiol Opt. 2004;24:274–280
    • View In Article
21. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and improving health. 2nd ed.. Washington, DC: U.S. Government Printing Office; November 2000;
    • View In Article
22. Duhl LJ. Health information community networks. Public Health Rep. 2000;115:271–273
    • View In Article
    • MEDLINE
    • CrossRef
23. National Eye Institute, National Institute of Health, Department of Health and Human Services, U.S.A. (2005). Healthy People 2010: Midcourse Review Vision and Hearing. Available at: http://www.healthyvision2010.org/about_hv/index.asp. Las accessed August 6, 2008.
    • View In Article
24. Centers for Disease Control and Prevention. Improving the nation's vision health: a coordinated public health approach. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation, Vision Health Initiative, 2006.
    • View In Article