Vision in Long-Term Care Facilities: An Overlooked Need

1. Vision in Long-Term Care Facilities: An Overlooked Need Dr. Pamela Hawranik Associate Professor Faculty of Nursing, U of MB Sandy Bell RN MN Director Quality & Education Services Misericordia Health Centre Acknowledgements: ►Fort Garry Legion Poppy Fund for funding the feasibility study ►Manitoba Health for funding the MHC Pilot project; ►Karen McCormac RN for conducting vision screening

2. Overview Background literature: Vision and aging Vision and independence Current practices Three Projects: ISurvey on Vision Care Services in LTC facilities II “Focus on Falls” Pilot Project at MHC III “Feasibility Study on Effectiveness of Screening”

3. Background • The issue of the lack of vision care services for residents living in a PCH setting is a global issue embedded in all types of health care systems, cultures and environments • Australia, Iran, Great Britain, US, China and Canada all indicate this lack of vision care access.

4. Vision and Aging In Canada, 13% of population is 65+ Projected to increase to over 23% by the year 2030 (Statistics Canada, 2001) In MB, 13.6% of older adults are 65+, with over 8% residing in PCHs (Statistics Canada, 2001) Research indicates that vision decline is directly related to the aging process (Houde & Huff, 2003)

5. Vision and Aging(cont’d) Visual deficits Cataracts Refractive errors Macular Degeneration Glaucoma Diabetic Retinopathy These are often undetected, but are preventable and/or treatable to a certain extent

6. Vision and Aging(cont’d) Estimates indicate that 20-50% of older people have undetected reduced vision, most suffering from refractive errors, and cataracts which are both correctable (Smeeth et al, 2003). Rates of eye disease and visual impairment among PCH residents is 3.3 times greater than any other segment of the population (Morer, 1994).

7. Vision and Independence Unrecognized visual impairment is a factor contributing to PCH placement and increased cognitive impairment (Van der Pols et al, 2000). Vision plays an important role in balance, mobility, falls and standing balance of older persons.

8. Vision and Independence(cont’d) Visual deficits contribute to falls, fractures, depression, increase in cognitive impairment and disruptive behaviors (Carnicelli, 2001). Fall related hip fractures in the elderly are higher in persons with visual impairment (Brannan et al, 2003).

9. Vision and Independence(cont’d) Falls are a major source of death and injury in the elderly (Harwood et al, 2005). Hip fractures are the most common fracture, the most devastating and the most costly to the health care system to treat (Kannus & Khan, 2001).

10. Current Practices ■ Vision care for the elderly in the PCH setting suffers from a lack of policy development. ■ Administrators, physicians, nurses, residents, families and government are unaware of the effects that visual deficits have on the quality of life and independence of the elderly (Johnston, 2001)

11. Current Practices • Health care is determined by assessing how much benefit is gained by a service in terms of life extension and/or improvement in quality of life. Vision care has not been viewed as medically necessary (National Advisory Council on Aging, 1995)

12. Definitions Vision Care Services: vision screening, vision assessment, referral, interventions, follow up of interventions. Visual Deficits: Refractory issues Cataracts Macular Degeneration Glaucoma Diabetic Retinopathy

13. I. Survey To examine the extent of vision care services provided in LTC facilities in: Aberdeen, Scotland Winnipeg, Manitoba To determine the relationship between vision impairment and falls.

14. Current Guidelines Canada and Manitoba: No specific guidelines Vision has not been deemed a “medically necessary health service” Scotland: Standards to assure quality services available Voluntary participation with a contract service Centre on Aging Spring Symposium 2008

15. Survey Methods Ethical Approval from U of MB & committee in Aberdeen Permission from WRHA with letter informing facilities of survey Questionnaire sent to all facilities in each city Closed and open ended questions

16. Survey Methods(cont’d) Mailed survey Characteristics of residents Characteristics of facility Presence or absence of vision care policy Nature of vision care services offered In-service education offered on vision Incidence of falls and fractures Telephone interview with facilities that indicated they have a vision care policy

17. Findings - Scotland N= 45 care homes Majority of residents female Range in size 40 to 80 beds Most care homes pre-entry eye testing Only 1 indicated a policy on vision care All provided a “Best guess” estimate of falls/fractures Number of falls/year ranged 20 to 156

18. Findings – Scotland (cont’d) Variations in documentation of vision health 77% of staff had no training on vision care or deficits 62% of care homes used Vision Call Scottish government to reform eye care for all older adults

19. Findings - Winnipeg N= 28 LTC facilities responded Facility size ranged from 60 to 420 beds Most residents were female 6/28 indicated a policy on vision care services 6/28 indicated they provide a vision care service at admission Each identified a different action and one action

20. Findings – Winnipeg (cont’d) 21 facilities indicated that if a referral is made, they do not conduct any follow-up to determine outcome of referral 1% to 8% of fractures were due to falls Facilities used different methods to report incidence of falls No data available that linked vision to falls

21. Findings – Winnipeg (cont’d) Falls per 1000 resident days, ranged from 5 to 30 12 facilities did not have data available # of falls/year, ranged 563-1994 13 facilities (44%) had a nursing procedure for care of vision aids; rarely more than one procedure was mentioned

22. Findings – Winnipeg (cont’d) 6 facilities indicated they provide education sessions on visual deficits and intervention 3 had not conducted such a session during the past six months

23. Manitoba Falls Prevention Program Vision Care Bone Health Medications Centre on Aging Spring Symposium 2008

24. II. Vision Care Pilot Project at MHC “Focus on Falls Prevention” pilot project: Three year project: 2006-2009 Collaborators Misericordia Health Centre Misericordia Health Centre Foundation Manitoba Health University of Manitoba Manitoba Association of Optometrists Canadian National Institute for the Blind

25. II. Vision Care Project at MHC Purpose To improve the Quality of Life for seniors in the Province of Manitoba To provide evidence to support improving vision in this population group and that it will impact positively on falls and fractures and overall health care budget and wait times.

26. Implementation Prepared 10 month schedule for participating PCHs. Three clinics per month, 15 residents per 5 hour clinic day: Target 450 optometry assessments : 360 actual , 90 cancelled. Optometrist schedule Staff education/ training sessions at PCH Equipment transferred Clinic days set up Resident assessments Centre on Aging Spring Symposium 2008

27. Vision Screening Tool • Designed to provide a quick and easy assessment of vision • Assesses vision and activities of daily living • All health care professionals • Useful in cognitively impaired residents and EAL • Referral algorithm

28. II. Vision Care Project at MHCYear I: March 2006-March 2007 Focused on MHC and residents both in the Interim and PCH setting All residents received vision screening and on site optometry assessments Referral system Family involvement Program established Research project initiated Centre on Aging Spring Symposium 2008

29. II. Vision Care Project at MHCYear I: March 2006-March 2007 LTC setting: All 370 residents screened displayed some type of visual impairment 20 residents with dementia were unable to be screened Community setting: All 150 individuals screened had some type of visual impairment Centre on Aging Spring Symposium 2008

30. II. Vision Care Project at MHCYear II March 2007- March 2008: Overwhelming response from WRHA PCH Program Participation included both For Profit and Not for Profit PCH settings Based on Falls Prevention Risk Assessments Centre on Aging Spring Symposium 2008

31. II. Vision Care Project at MHCYear II March 2007- March 2008: 9 PCHs in WRHA participated High risk for falls Target to screen 400 older adults 65% of residents screened referred All residents exhibited some vision impairment Centre on Aging Spring Symposium 2008

32. II. Vision Care Project at MHCYear III March 2008- March 2009 Continue with WRHA PCH setting and community settings Move into other RHAs: Interlake , NEHA Training to community and RHA groups U of M Faculty of Nursing students Acute care interest Marketing of tool and program to other provinces Future research: Elderly presenting in ER with recurrent falls Centre on Aging Spring Symposium 2008

33. Falls: 2005/2006 Vs. Year I

34. Falls: Year I Vs. Year II

35. Falls per 1000 Resident Days • 2005-2006: • 8.5 Falls per 1000 days • 2006-2007: • 7.6 Falls per 1000 days • Year I: April – Dec 2006: • 7.2 Falls per 1000 days • Year II: April – Dec 2007: • 5.5 Falls per 1000 days

36. III. Feasibility Study of Screening Process Sample of subgroup of MHC residents who participated in the pilot project Fall 2006 to summer 2007 Before and after screening/treatment data collection Ethical approval and access permission obtained

37. III. Examination of Effectiveness of Screening (cont’d) Objectives To identify prevalence of vision disorders To test reliability and validity of vision screening tool. To compare prevalence of falls and various quality of life characteristics before and after treatment.

38. III. Examination of Effectiveness of Screening (cont’d) Sample Characteristics N=92 Female n=76 (82.6%) Age Range = 63-102 Vision dx at admission n= 17 (18%) Wore glasses n=69 (75%) No recorded data on last eye exam or if one had taken place n=70 (75%) Fell in past 6 months n=19 (20%)

39. Findings Screening Tool Screening by Nurse found 77 with vision impairment while the optometrist found 79 with vision impairment – 97.5% agreement Nurse referred: 52 for ophthalmology and 25 for optometry Optometrist determined: 49 for ophthalmology and 28 for optometry Strength of association between nurse and optometrist assessment: .799 (excellent)

40. Findings(cont’d) 74 did not have a vision impairment dx at admission or in other words, only 18 had a dx Upon screening, 72 were found with vision impairment

41. Findings - Intervention Intervention provided n=17 Those who had intervention, a significant improvement in level of depression, social engagement, balance and a decrease in falls and no fractures No critical incidents in those who had an intervention

42. Findings - No intervention Refused intervention n=29 Did not see the specialist due to mobility and transfer difficulties n=7 • Falls: 18 • Critical Incidents : 8 • Fractures: Hip 5, wrist 2, ribs 1 • Deaths : 3 deaths , hip fractures and refusal for vision intervention.

43. Findings -Cognitive Performance Scale, Depression, Social Engagement, Quality of Life and Balance • All 17 residents who had vision interventions had improvements in at least one of these areas. There were no deteriorations noted • All 36 residents who did not have vision interventions had deterioration in one or more of these areas.

44. Findings Logistic regression 2 predictors of falls post-intervention i) If had a previous fall (O.R.= 3.5, 1.06 – 11.2) ii) if refused or did not receive intervention (O.R.=3.09, 1.13 – 8.44)

45. Conclusion The screening tool was easily used by the nurses The screening tool was highly reliable in detecting vision impairment and in directing to the correct professional Vision impairment has gone undetected Those who had no intervention were at greater risk for falls and fractures than those who obtained intervention

46. Implications Screening with this tool reliable when used by nurses Majority of residents needed some treatment Vision care a major gap in our care of older adults Vision an important factor in independence Reasons for family/resident refusal of treatment surprising Lack of education of staff, residents, and family

47. Feasibility of a Vision Screening Program in Manitoba • Of the $819 million per year spent on unintentional injuries, $335 million is related to falls with $164 million devoted to treating falls among the elderly (Papadimitropoulos et al., 1997) • In 2001, Seniors> 80 used 32 % of all hospital days (Statistics Canada) • It is estimated that 40% of falls leading to hospitalization are the result of hip fractures. This number will increase dramatically: 38.5% over the next 30 years (Papadimitropoulos et al., 1997)

48. Feasibility (cont’d) • Manitoba is projected to have the second highest percent of visual impairment and blindness in Canada by 2026 • The average cost for a general vision examination in Manitoba is $50-70; cataract surgery is $1200, and hip surgery required due to a hip fracture from a fall is upwards of $36,000 • Based on these statistics and the current research and discussion of literature, there is a need for a vision screening program in the Province of Manitoba

49. Your Questions ? pam_hawranik@umanitoba.ca sbell@miseri.winnipeg.mb.ca