Vision in Long-Term Care Facilities: An Overlooked Need

Vision in Long-Term Care Vision in Long-Term Care Facilities: An Overlooked NeedFacilities: An Overlooked Need

Dr. Pamela Hawranik Dr. Pamela Hawranik Associate ProfessorAssociate Professor

Faculty of Nursing, U of MBFaculty of Nursing, U of MB

Sandy Bell RN MNSandy Bell RN MNDirector Quality & Education ServicesDirector Quality & Education Services

Misericordia Health CentreMisericordia Health Centre

Acknowledgements: Acknowledgements: ►►Fort Garry Legion Poppy Fund for funding the feasibility studyFort Garry Legion Poppy Fund for funding the feasibility study►►Manitoba Health for funding the MHC Pilot project;Manitoba Health for funding the MHC Pilot project;►►Karen McCormac RN for conducting vision screeningKaren McCormac RN for conducting vision screening

Centre on Aging Spring Symposium 2008

OverviewOverview

Background literatureBackground literature:: Vision and agingVision and aging Vision and independenceVision and independence Current practicesCurrent practices

Three Projects:Three Projects:

II Survey on Vision Care Services in LTC facilitiesSurvey on Vision Care Services in LTC facilities

IIII “ “Focus on FallsFocus on Falls” Pilot Project at MHC” Pilot Project at MHC

IIIIII “Feasibility Study on Effectiveness of Screening” “Feasibility Study on Effectiveness of Screening”

BackgroundBackground

The issue of the lack of vision care The issue of the lack of vision care services for residents living in a PCH services for residents living in a PCH setting is a global issue embedded in all setting is a global issue embedded in all types of health care systems, cultures and types of health care systems, cultures and environmentsenvironments

Australia, Iran, Great Britain, US, China Australia, Iran, Great Britain, US, China and Canada all indicate this lack of vision and Canada all indicate this lack of vision care access. care access.


Vision and AgingVision and Aging

In Canada, 13% of population is 65+ In Canada, 13% of population is 65+ Projected to increase to over 23% by the Projected to increase to over 23% by the

year 2030 year 2030 (Statistics Canada, 2001)(Statistics Canada, 2001)

In MB, 13.6% of older adults are 65+, with In MB, 13.6% of older adults are 65+, with over 8% residing in PCHs over 8% residing in PCHs (Statistics Canada, 2001)(Statistics Canada, 2001)

Research indicates that vision decline is Research indicates that vision decline is directly related to the aging process directly related to the aging process (Houde & (Houde & Huff, 2003)Huff, 2003)


Vision and AgingVision and Aging (cont’d)(cont’d)

Visual deficitsVisual deficits CataractsCataracts Refractive errorsRefractive errors Macular DegenerationMacular Degeneration GlaucomaGlaucoma Diabetic RetinopathyDiabetic Retinopathy

These are often undetected, but are preventable These are often undetected, but are preventable and/or treatable to a certain extentand/or treatable to a certain extent


Vision and AgingVision and Aging (cont’d)(cont’d)

Estimates indicate that 20-50% of older Estimates indicate that 20-50% of older people have undetected reduced vision, people have undetected reduced vision, most suffering from refractive errors, and most suffering from refractive errors, and cataracts which are both correctablecataracts which are both correctable (Smeeth (Smeeth et al, 2003).et al, 2003).

Rates of eye disease and visual Rates of eye disease and visual impairment among PCH residents is 3.3 impairment among PCH residents is 3.3 times greater than any other segment of times greater than any other segment of the population the population (Morer, 1994).(Morer, 1994).


Vision and IndependenceVision and Independence

Unrecognized visual impairment is a factor Unrecognized visual impairment is a factor contributing to PCH placement and contributing to PCH placement and increased cognitive impairment increased cognitive impairment (Van der Pols et (Van der Pols et al, 2000).al, 2000).

Vision plays an important role in balance, Vision plays an important role in balance, mobility, falls and standing balance of mobility, falls and standing balance of older persons.older persons.


Vision and IndependenceVision and Independence (cont’d)(cont’d)

Visual deficits contribute to falls, fractures, Visual deficits contribute to falls, fractures, depression, increase in cognitive depression, increase in cognitive impairment and disruptive behaviors impairment and disruptive behaviors (Carnicelli, 2001).(Carnicelli, 2001).

Fall related hip fractures in the elderly are Fall related hip fractures in the elderly are higher in persons with visual impairment higher in persons with visual impairment (Brannan et al, 2003).(Brannan et al, 2003).


Vision and IndependenceVision and Independence (cont’d)(cont’d)

Falls are a major source of death and Falls are a major source of death and injury in the elderly injury in the elderly (Harwood et al, 2005).(Harwood et al, 2005).

Hip fractures are the most common Hip fractures are the most common fracture, the most devastating and the fracture, the most devastating and the most costly to the health care system to most costly to the health care system to treat treat (Kannus & Khan, 2001).(Kannus & Khan, 2001).

Current PracticesCurrent Practices

■ ■ Vision care for the elderly in the PCH Vision care for the elderly in the PCH setting suffers from a lack of policy setting suffers from a lack of policy development. development.

■ ■ Administrators, physicians, nurses, Administrators, physicians, nurses, residents, families and government are residents, families and government are unaware of the effects that visual deficits unaware of the effects that visual deficits have on the quality of life and have on the quality of life and independence of the elderly independence of the elderly (Johnston, 2001)(Johnston, 2001)

Current PracticesCurrent Practices

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


DefinitionsDefinitions

Vision Care ServicesVision Care Services: vision screening, : vision screening, vision assessment, referral, interventions, vision assessment, referral, interventions, follow up of interventions. follow up of interventions.

Visual Deficits:Visual Deficits: Refractory issuesRefractory issues CataractsCataracts Macular DegenerationMacular Degeneration GlaucomaGlaucoma Diabetic RetinopathyDiabetic Retinopathy


I. SurveyI. Survey

To examine the extent of vision care To examine the extent of vision care services provided in LTC facilities in:services provided in LTC facilities in: Aberdeen, ScotlandAberdeen, Scotland Winnipeg, ManitobaWinnipeg, Manitoba

To determine the relationship between To determine the relationship between vision impairment and falls.vision impairment and falls.


Current GuidelinesCurrent Guidelines

Canada and Manitoba:Canada and Manitoba: No specific guidelinesNo specific guidelines Vision has not been deemed a “medically Vision has not been deemed a “medically

necessary health service”necessary health service”

Scotland:Scotland: Standards to assure quality services availableStandards to assure quality services available Voluntary participation with a contract serviceVoluntary participation with a contract service


Survey MethodsSurvey Methods

Ethical Approval from U of MB & Ethical Approval from U of MB & committee in Aberdeencommittee in Aberdeen

Permission from WRHA with letter Permission from WRHA with letter informing facilities of surveyinforming facilities of survey

Questionnaire sent to all facilities in each Questionnaire sent to all facilities in each citycity

Closed and open ended questionsClosed and open ended questions

Survey MethodsSurvey Methods (cont’d)(cont’d)

Mailed survey Mailed survey Characteristics of residentsCharacteristics of residents Characteristics of facilityCharacteristics of facility Presence or absence of vision care policyPresence or absence of vision care policy Nature of vision care services offeredNature of vision care services offered In-service education offered on visionIn-service education offered on vision Incidence of falls and fracturesIncidence of falls and fractures

Telephone interview with facilities that Telephone interview with facilities that indicated they have a vision care policyindicated they have a vision care policy


Findings Findings - Scotland- Scotland

N= 45 care homesN= 45 care homes Majority of residents femaleMajority of residents female Range in size 40 to 80 bedsRange in size 40 to 80 beds Most care homes pre-entry eye testingMost care homes pre-entry eye testing Only 1 indicated a policy on vision careOnly 1 indicated a policy on vision care All provided a “Best guess” estimate of All provided a “Best guess” estimate of

falls/fracturesfalls/fractures Number of falls/year ranged 20 to 156Number of falls/year ranged 20 to 156


FindingsFindings – Scotland – Scotland (cont’d)(cont’d)

Variations in documentation of vision Variations in documentation of vision healthhealth

77% of staff had no training on vision care 77% of staff had no training on vision care or deficitsor deficits

62% of care homes used Vision Call62% of care homes used Vision Call Scottish government to reform eye care for Scottish government to reform eye care for

all older adultsall older adults


FindingsFindings - Winnipeg - Winnipeg

N= 28 LTC facilities respondedN= 28 LTC facilities responded Facility size ranged from 60 to 420 bedsFacility size ranged from 60 to 420 beds Most residents were femaleMost residents were female 6/28 indicated a policy on vision care 6/28 indicated a policy on vision care

servicesservices 6/28 indicated they provide a vision care 6/28 indicated they provide a vision care

service at admissionservice at admission Each identified a different action and one Each identified a different action and one

actionaction


FindingsFindings – Winnipeg – Winnipeg (cont’d)(cont’d)

21 facilities indicated that if a referral is 21 facilities indicated that if a referral is made, they do not conduct any follow-up made, they do not conduct any follow-up to determine outcome of referralto determine outcome of referral

1% to 8% of fractures were due to falls1% to 8% of fractures were due to falls Facilities used different methods to report Facilities used different methods to report

incidence of fallsincidence of falls No data available that linked vision to fallsNo data available that linked vision to falls



Falls per 1000 resident days, ranged from Falls per 1000 resident days, ranged from 5 to 305 to 30

12 facilities did not have data available12 facilities did not have data available # of falls/year, ranged 563-1994# of falls/year, ranged 563-1994 13 facilities (44%) had a nursing 13 facilities (44%) had a nursing

procedure for care of vision aids; rarely procedure for care of vision aids; rarely more than one procedure was mentionedmore than one procedure was mentioned



6 facilities indicated they provide 6 facilities indicated they provide education sessions on visual deficits and education sessions on visual deficits and interventionintervention

3 had not conducted such a session 3 had not conducted such a session during the past six monthsduring the past six months


Manitoba Falls Prevention Manitoba Falls Prevention ProgramProgram

Vision CareVision Care

Bone HealthBone Health

MedicationsMedications


II. Vision Care Pilot Project at MHCII. Vision Care Pilot Project at MHC

““Focus on Falls PreventionFocus on Falls Prevention” pilot project: ” pilot project: Three year project: 2006-2009Three year project: 2006-2009

CollaboratorsCollaborators Misericordia Health CentreMisericordia Health Centre Misericordia Health Centre FoundationMisericordia Health Centre Foundation Manitoba HealthManitoba Health University of ManitobaUniversity of Manitoba Manitoba Association of OptometristsManitoba Association of Optometrists Canadian National Institute for the BlindCanadian National Institute for the Blind


II. Vision Care Project at MHCII. Vision Care Project at MHC

PurposePurpose

To improve the Quality of Life for seniors in To improve the Quality of Life for seniors in the Province of Manitobathe Province of Manitoba

To provide evidence to support improving To provide evidence to support improving vision in this population group and that it will vision in this population group and that it will impact positively on falls and fractures and impact positively on falls and fractures and overall health care budget and wait times.overall health care budget and wait times.


ImplementationImplementation

Prepared 10 month schedule for participating Prepared 10 month schedule for participating PCHs. Three clinics per month, 15 residents per PCHs. Three clinics per month, 15 residents per 5 hour clinic day: Target 450 optometry 5 hour clinic day: Target 450 optometry assessments : 360 actual , 90 cancelled.assessments : 360 actual , 90 cancelled.

Optometrist schedule Optometrist schedule Staff education/ training sessions at PCHStaff education/ training sessions at PCH Equipment transferred Equipment transferred Clinic days set upClinic days set up Resident assessmentsResident assessments

Vision Screening ToolVision Screening Tool

Designed to provide a quick and easy Designed to provide a quick and easy assessment of vision assessment of vision

Assesses vision and activities of daily Assesses vision and activities of daily livingliving

All health care professionals All health care professionals Useful in cognitively impaired residents Useful in cognitively impaired residents

and EALand EAL Referral algorithmReferral algorithm


II. Vision Care Project at MHCII. Vision Care Project at MHC Year I: March 2006-March 2007Year I: March 2006-March 2007

Focused on MHC and residents both in Focused on MHC and residents both in the Interim and PCH settingthe Interim and PCH setting

All residents received vision screening All residents received vision screening and on site optometry assessmentsand on site optometry assessments

Referral systemReferral system Family involvementFamily involvement Program establishedProgram established Research project initiatedResearch project initiated


II. Vision Care Project at MHCII. Vision Care Project at MHC Year I: March 2006-March 2007Year I: March 2006-March 2007

LTC setting:LTC setting:All 370 residents screened displayed All 370 residents screened displayed

some type of visual impairmentsome type of visual impairment20 residents with dementia were 20 residents with dementia were

unable to be screenedunable to be screened Community setting:Community setting:

All 150 individuals screened had some All 150 individuals screened had some type of visual impairmenttype of visual impairment


II. Vision Care Project at MHCII. Vision Care Project at MHCYear II March 2007- March 2008:Year II March 2007- March 2008:

Overwhelming response from WRHA PCH Overwhelming response from WRHA PCH ProgramProgram

Participation included both For Profit Participation included both For Profit and Not for Profit PCH settingsand Not for Profit PCH settings

Based on Falls Prevention Risk Based on Falls Prevention Risk AssessmentsAssessments


II. Vision Care Project at MHCII. Vision Care Project at MHCYear II March 2007- March 2008:Year II March 2007- March 2008:

9 PCHs in WRHA participated9 PCHs in WRHA participated High risk for fallsHigh risk for falls Target to screen 400 older adultsTarget to screen 400 older adults 65% of residents screened referred65% of residents screened referred All residents exhibited some vision All residents exhibited some vision

impairmentimpairment


II. Vision Care Project at MHCII. Vision Care Project at MHCYear III March 2008- March 2009Year III March 2008- March 2009 Continue with WRHA PCH setting and community Continue with WRHA PCH setting and community

settingssettings Move into other RHAs: Interlake , NEHAMove into other RHAs: Interlake , NEHA Training to community and RHA groupsTraining to community and RHA groups U of M Faculty of Nursing students U of M Faculty of Nursing students Acute care interestAcute care interest Marketing of tool and program to other provincesMarketing of tool and program to other provinces Future research: Elderly presenting in ER with Future research: Elderly presenting in ER with

recurrent fallsrecurrent falls

Falls: 2005/2006 Vs. Year IFalls: 2005/2006 Vs. Year I

310

279

260265270275280285290295300305310

April 1, 2005 -Mar. 31, 2006

Apr.1, 2006 - Mar.31, 2007

Misercordia Place

Falls: Year I Vs. Year IIFalls: Year I Vs. Year II

199

152

100110120130140150160170180190200

April 1, 2006 -Dec. 31, 2006

April 1, 2007 -Dec. 31, 2007

MisercoridaPlace Falls

Falls per 1000 Resident DaysFalls per 1000 Resident Days

2005-2006:2005-2006: 8.5 Falls per 1000 days8.5 Falls per 1000 days

2006-2007:2006-2007: 7.6 Falls per 1000 days7.6 Falls per 1000 days

Year I: April – Dec 2006:Year I: April – Dec 2006: 7.2 Falls per 1000 days7.2 Falls per 1000 days

Year II: April – Dec 2007:Year II: April – Dec 2007: 5.5 Falls per 1000 days5.5 Falls per 1000 days


III. Feasibility Study of Screening III. Feasibility Study of Screening ProcessProcess

Sample of subgroup of MHC residents Sample of subgroup of MHC residents who participated in the pilot projectwho participated in the pilot project

Fall 2006 to summer 2007Fall 2006 to summer 2007 Before and after screening/treatment data Before and after screening/treatment data

collectioncollection Ethical approval and access permission Ethical approval and access permission

obtainedobtained


III. Examination of Effectiveness of III. Examination of Effectiveness of Screening Screening (cont’d)(cont’d)

ObjectivesObjectives To identify prevalence of vision disordersTo identify prevalence of vision disorders To test reliability and validity of vision To test reliability and validity of vision

screening tool.screening tool. To compare prevalence of falls and To compare prevalence of falls and

various quality of life characteristics before various quality of life characteristics before and after treatment.and after treatment.


III. Examination of Effectiveness of III. Examination of Effectiveness of Screening Screening (cont’d)(cont’d)

Sample Characteristics N=92Sample Characteristics N=92 Female n=76 (82.6%)Female n=76 (82.6%) Age Range = 63-102Age Range = 63-102 Vision dx at admission n= 17 (18%)Vision dx at admission n= 17 (18%) Wore glasses n=69 (75%)Wore glasses n=69 (75%) No recorded data on last eye exam or if one No recorded data on last eye exam or if one

had taken place n=70 (75%)had taken place n=70 (75%) Fell in past 6 months n=19 (20%)Fell in past 6 months n=19 (20%)


Findings Findings

Screening ToolScreening Tool Screening by Nurse found 77 with vision Screening by Nurse found 77 with vision

impairment while the optometrist found 79 with impairment while the optometrist found 79 with vision impairment – vision impairment – 97.5% agreement97.5% agreement

Nurse referred: 52 for ophthalmology and 25 for Nurse referred: 52 for ophthalmology and 25 for optometryoptometry

Optometrist determined: 49 for ophthalmology Optometrist determined: 49 for ophthalmology and 28 for optometryand 28 for optometry Strength of association between nurse and Strength of association between nurse and

optometrist assessment: .799 (excellent)optometrist assessment: .799 (excellent)


FindingsFindings (cont’d)(cont’d)

74 did not have a vision impairment dx at 74 did not have a vision impairment dx at admission or admission or in other wordsin other words, only , only 18 18 had had a dxa dx

Upon screening, Upon screening, 7272 were found with vision were found with vision impairmentimpairment


Findings -Findings - Intervention Intervention

Intervention provided n=17Intervention provided n=17 Those who had intervention, Those who had intervention,

a significant improvement in level of a significant improvement in level of depression, social engagement, balance depression, social engagement, balance and a decrease in falls and no fracturesand a decrease in falls and no fractures

No critical incidents in those who had an No critical incidents in those who had an interventionintervention

Findings - Findings - No interventionNo intervention

Refused intervention n=29Refused intervention n=29Did not see the specialist due to mobility Did not see the specialist due to mobility

and transfer difficulties n=7and transfer difficulties n=7Falls: Falls: 1818

Critical Incidents : 8Critical Incidents : 8Fractures: Hip 5, wrist 2, ribs 1Fractures: Hip 5, wrist 2, ribs 1Deaths : 3 deaths , hip fractures Deaths : 3 deaths , hip fractures

and refusal for vision and refusal for vision intervention.intervention.

FindingsFindings - -Cognitive Performance Scale, Cognitive Performance Scale, Depression, Social Engagement, Depression, Social Engagement,

Quality of Life and BalanceQuality of Life and Balance

All 17 residents who had vision interventions All 17 residents who had vision interventions had improvements in at least one of these had improvements in at least one of these areas. There were no deteriorations notedareas. There were no deteriorations noted

All 36 residents who did not have vision All 36 residents who did not have vision interventions had deterioration in one or more of interventions had deterioration in one or more of these areas.these areas.

MNRI research seminar 09/2007

FindingsFindings

Logistic regression Logistic regression 2 predictors of falls post-intervention2 predictors of falls post-intervention

i) If had a previous fall (O.R.= 3.5, i) If had a previous fall (O.R.= 3.5, 1.06 – 11.2) 1.06 – 11.2)

ii) if refused or did not receive ii) if refused or did not receive intervention (O.R.=3.09, 1.13 – 8.44)intervention (O.R.=3.09, 1.13 – 8.44)

MNRI research seminar 09/2007

ConclusionConclusion

The screening tool was easily used by the The screening tool was easily used by the nursesnurses

The screening tool was highly reliable in The screening tool was highly reliable in detecting vision impairment and in detecting vision impairment and in directing to the correct professionaldirecting to the correct professional

Vision impairment has gone undetected Vision impairment has gone undetected Those who had no intervention were at Those who had no intervention were at

greater risk for falls and fractures than greater risk for falls and fractures than those who obtained interventionthose who obtained intervention

Centre on Aging Spring Symposium

ImplicationsImplications

Screening with this tool reliable when used Screening with this tool reliable when used by nursesby nurses

Majority of residents needed some treatmentMajority of residents needed some treatment Vision care a major gap in our care of older Vision care a major gap in our care of older

adultsadults Vision an important factor in independenceVision an important factor in independence Reasons for family/resident refusal of Reasons for family/resident refusal of

treatment surprisingtreatment surprising Lack of education of staff, residents, and Lack of education of staff, residents, and

familyfamily

Feasibility of a Vision Screening Feasibility of a Vision Screening Program in ManitobaProgram in Manitoba

Of the $819 million per year spent on Of the $819 million per year spent on unintentional injuries, $335 million is related to unintentional injuries, $335 million is related to falls with $164 million devoted to treating falls falls with $164 million devoted to treating falls among the elderly among the elderly (Papadimitropoulos et al., 1997)(Papadimitropoulos et al., 1997)

In 2001, Seniors> 80 used 32 % of all hospital In 2001, Seniors> 80 used 32 % of all hospital days (Statistics Canada)days (Statistics Canada)

It is estimated that 40% of falls leading to It is estimated that 40% of falls leading to hospitalization are the result of hip fractures. hospitalization are the result of hip fractures. This number will increase dramatically: 38.5% This number will increase dramatically: 38.5% over the next 30 years over the next 30 years (Papadimitropoulos et al., 1997)(Papadimitropoulos et al., 1997)

FeasibilityFeasibility (cont’d) (cont’d)

Manitoba is projected to have the second highest Manitoba is projected to have the second highest percent of visual impairment and blindness in percent of visual impairment and blindness in Canada by 2026Canada by 2026

The average cost for a general vision examination The average cost for a general vision examination in Manitoba is in Manitoba is $50-70$50-70; cataract surgery is ; cataract surgery is $$12001200, and hip surgery required due to a hip , and hip surgery required due to a hip fracture from a fall is upwards of fracture from a fall is upwards of $36,000$36,000

Based on these statistics and the current research Based on these statistics and the current research and discussion of literature, there is a need for a and discussion of literature, there is a need for a vision screening program in the Province of vision screening program in the Province of ManitobaManitoba

Your QuestionsYour Questions

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[email protected]@miseri.winnipeg.mb.ca

Vision in Long-Term Care Facilities: An Overlooked Need

Documents

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