Associations Between Self-Reported Visual and Hearing Functioning and Cognitive Function Among Hispanics/Latino: Hispanic Community Health Study.

Background and Objectives: To investigate the associations between self-reported visual functioning (VF) and hearing functioning with cognition in the Hispanic/Latino population. Research Design and Methods: We utilized data from the Miami Ocular Study of Latinos ancillary study to Hispanic Community Health Study/Study of Latinos with 1,056 participants aged 45 and older. The outcomes were cognitive performances assessed by the Digit Symbol Substitution Test (DSST), Word Fluency, Brief-Spanish English Verbal Learning Test-recall (B-SEVLT recall), words recalled over 3 trials, and the Six-Item Screener. VF was measured by National Eye Institute Visual Function Questionnaire (NEI-VFQ), and hearing function was measured by Hearing Handicap Inventory Screening Questionnaire for Adults and Elderly (HHIA/E-S). Multiple regressions were performed for each cognitive outcome while controlling for covariates and complex sampling design. Results: NEI-VFQ was associated with 3 of the 5 cognitive outcomes. A 4-point NEI-VFQ score difference was associated with a 0.56-point difference in DSST (standard error [SE] = 0.27, p < .001), 0.17 in Word fluency (SE = 0.16, p < .01), and 0.08 in B-SEVLT-recall (SE = 0.07, p < .01). HHIA/E-S was not associated with any of the cognitive measures examined. Discussion and Implications: These data suggest that impaired VF is associated with worse cognition in the Hispanic/Latino population. Although previous work in this cohort indicated hearing loss assessed by pure tone audiometry was associated with worse cognition, we found self-perceived hearing function was not associated with cognition, suggesting the potential limitation of self-reported hearing function as a proxy for hearing loss in epidemiological research in Hispanic/Latino populations. Results also imply impaired VF and hearing function may be linked to cognition differently in the Hispanic population, and more research is needed to better understand the underlying linking mechanisms. Visual and hearing impairments are common and treatable and represent important modifiable risk factors that can be treated to preserve cognitive function in Hispanics/Latinos.

Leber Hereditary Optic Neuropathy Gene Therapy: Longitudinal Relationships Among Visual Function and Anatomical Measures.

PURPOSE: To assess longitudinal relationships among visual function and anatomical measures of gene therapy in G11778A Leber hereditary optic neuropathy (LHON). DESIGN: Phase 1 clinical trial. METHODS: This was a single-institution study of patients with G11778A LHON. Patients with chronic bilateral visual loss >12 months (group 1, n = 11), acute bilateral visual loss <12 months (group 2, n = 9), or unilateral visual loss (group 3, n = 8) were administered unilateral intravitreal AAV2(Y444,500,730F)-P1ND4v2 injection with low, medium, high, and higher doses to worse eye for groups 1 and 2 and better eye for group 3. Oucome measures were best-corrected visual acuity (BCVA), visual field mean deviation (VF MD), steady-state pattern electroretinogram (SS-PERG), optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) thickness and ganglion cell+inner plexiform layer (GCIPL) thickness, and National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) scores. Mean follow-up was 33.6 months (range = 18-36 months). RESULTS: Baseline SS-PERG amplitude was much reduced in both eyes of all groups including asymptomatic eyes of group 3, and showed no appreciable changes irrespective of disease stage and treatment. Significant and progressive GCIPL and RNFL thinning occurred in all eyes; BCVA and VF MD fluctuated in treated and fellow eyes, with some eyes having modest improvement that may be related to natural history or to gene therapy. Mean NEI-VFQ-25 scores declined in group 3 subjects (P = .023), CONCLUSION: Asymptomatic eyes in LHON patients with unilateral visual loss may be beyond the window of effective neuroprotection given reduced GCIPL and SS-PERG. Randomization of patients to an untreated control group would help to assess treatment effect by accounting for variable natural history. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

A Novel Computerized Cognitive Test for the Detection of Mild Cognitive Impairment and Its Association with Neurodegeneration in Alzheimer's Disease Prone Brain Regions.

During the prodromal stage of Alzheimer's disease (AD), neurodegenerative changes can be identified by measuring volumetric loss in AD-prone brain regions on MRI. Cognitive assessments that are sensitive enough to measure the early brain-behavior manifestations of AD and that correlate with biomarkers of neurodegeneration are needed to identify and monitor individuals at risk for dementia. Weak sensitivity to early cognitive change has been a major limitation of traditional cognitive assessments. In this study, we focused on expanding our previous work by determining whether a digitized cognitive stress test, the Loewenstein-Acevedo Scales for Semantic Interference and Learning, Brief Computerized Version (LASSI-BC) could differentiate between Cognitively Unimpaired (CU) and amnestic Mild Cognitive Impairment (aMCI) groups. A second focus was to correlate LASSI-BC performance to volumetric reductions in AD-prone brain regions. Data was gathered from 111 older adults who were comprehensively evaluated and administered the LASSI-BC. Eighty-seven of these participants (51 CU; 36 aMCI) underwent MR imaging. The volumes of 12 AD-prone brain regions were related to LASSI-BC and other memory tests correcting for False Discovery Rate (FDR). Results indicated that, even after adjusting for initial learning ability, the failure to recover from proactive semantic interference (frPSI) on the LASSI-BC differentiated between CU and aMCI groups. An optimal combination of frPSI and initial learning strength on the LASSI-BC yielded an area under the ROC curve of 0.876 (76.1% sensitivity, 82.7% specificity). Further, frPSI on the LASSI-BC was associated with volumetric reductions in the hippocampus, amygdala, inferior temporal lobes, precuneus, and posterior cingulate.

Persistent Failure to Recover from Proactive Semantic Interference on the Cognitive Stress Test Differentiates Between Amnestic Mild Cognitive Impairment, Pre-Mild Cognitive Impairment, and Cognitively Unimpaired Older Adults.

BACKGROUND: Susceptibility to proactive semantic interference (PSI) and the inability to ameliorate these difficulties with one additional learning trial have repeatedly been implicated as early features of incipient Alzheimer's disease (AD). Unfortunately, persistent failure to recover from PSI (frPSI) after repeated learning trials, are not captured by existing memory measures, or been examined in pre-mild cognitive impairment (PreMCI). OBJECTIVE: A novel Cognitive Stress Test (CST) was employed to measure the impact of PSI, initial failure to recover from PSI and persistent effects of PSI, despite multiple learning trials of the new to-be-remembered material (pfrPSI). We hypothesized that PSI deficits on the CST would persist in both PreMCI and amnestic MCI (aMCI) groups over repeated learning trials when compared to cognitively unimpaired (CU) older adults. METHODS: One hundred fifty older adults (69 CU, 31 PreMCI, and 50 aMCI) underwent a standardized clinical and neuropsychological evaluation. The CST was independent of diagnostic classification. RESULTS: Even after adjusting for strength of initial learning, aMCI and PreMCI groups demonstrated greater persistent PSI (pfrPSI) relative to the CU group despite repeated learning trials of List B. Further, the aMCI group made a higher number of semantic intrusion errors relative to the PreMCI and CU groups on all List B Cued Recall trials. CONCLUSION: Persistent PSI appears to be a common feature of aMCI and PreMCI. The possible theoretical mechanisms and empirical implications of these new findings are discussed.

Semantic intrusion errors as a function of age, amyloid, and volumetric loss: a confirmatory path analysis.

OBJECTIVE: To examine the direct and indirect effects of age, APOE ϵ4 genotype, amyloid positivity, and volumetric reductions in AD-prone brain regions as it relates to semantic intrusion errors reflecting proactive semantic interference (PSI) and the failure to recover from proactive semantic interference (frPSI) on the Loewenstein-Acevedo Scales of Semantic Interference and Learning (LASSI-L), a cognitive stress test that has been consistently more predictive of preclinical and prodromal Alzheimer's disease (AD) than traditional list-learning tests. DESIGN: Cross-sectional study. SETTING: 1Florida Alzheimer's Disease Research Center baseline study. PARTICIPANTS: Two-hundred and twelve participants with Mini-Mental State Examination (MMSE) score above 16 and a broad array of cognitive diagnoses ranging from cognitively normal (CN) to dementia, of whom 58% were female, mean age of 72.1 (SD 7.9). MEASURES: Participants underwent extensive clinical and neuropsychological evaluations, MR and amyloid Positron Emission Tomography/Computer/Computer Tomography (PET/CT) imaging, and analyses of APOE ϵ4 genotype. Confirmatory path analyses were conducted in the structural equation modeling framework that estimated multiple equations simultaneously while controlling for important covariates such as sex, education, language of evaluation, and global cognitive impairment. RESULTS: Both amyloid positivity and decreased brain volumes in AD-prone regions were directly related to LASSI-L Cued B1 and Cued B2 intrusions (sensitive to PSI and frPSI effects) even after controlling for covariates. APOE ϵ4 status did not evidence direct effects on these LASSI-L cognitive markers, but rather exerted their effects on amyloid positivity, which in turn related to PSI and frPSI. Similarly, age did not have a direct relationship with LASSI-L scores, but exerted its effects indirectly through amyloid positivity and volumes of AD-prone brain regions. CONCLUSIONS: Our study provides insight into the relationships among age, APOE ϵ4, amyloid, and brain volumetric reductions as it relates to semantic intrusion errors. The investigation expands our understanding of the underpinnings of PSI and frPSI intrusions in a large cohort.

Visual Acuity, Retinal Morphology, and Patients' Perceptions after Voretigene Neparovec-rzyl Therapy for RPE65-Associated Retinal Disease.

OBJECTIVE: To explore the effect of patients' age, baseline visual acuity (VA), and intraoperative foveal detachment on outcomes of subretinal voretigene neparvovec-rzyl (Luxturna) therapy and to assess patients' perceptions of the treatment effect. DESIGN: Multicenter, retrospective, consecutive case series, and cross-sectional prospective survey. PARTICIPANTS: All 41 consecutive patients treated with voretigene neparvovec-rzyl after Food and Drug Administration approval at 3 institutions between January 2018 and May 2020. METHODS: A retrospective chart review of operative reports, clinical notes, ancillary testing, and complications, comparing data at baseline and at 1, 2 to 3, 6 to 9, and 10 to 15 months after subretinal surgery was conducted. A survey was administered to adult patients and parents of pediatric patients. MAIN OUTCOME MEASURES: Changes in best-corrected VA and retinal morphology and in patients' perceptions. RESULTS: Seventy-seven eyes of 41 patients (16 adults and 25 pediatric patients; age range, 2-44 years; mean follow-up, 10 months [range, 1 week to 18.5 months]) were analyzed. There was no statistically significant vision change for the adults, whereas there was a trend of improvement for pediatric patients, which reached statistical significance for some time points. The baseline VA did not affect the posttherapy VA (P = 0.23). The central foveal thickness decreased mildly in both pediatric patients and adults, without significant differences between the populations. The fovea was detached by voretigene neparvovec-rzyl in 62 (81%) eyes. The inner segment-outer segment junction remained unchanged in 91% of 54 eyes with gradable OCT, with or without foveal detachment. Thirty-two (78%) patients were reached for the survey an average of 1.15 ± 0.50 years (range, 0.31 to 2.31) after the surgery in the first eye. Improvement in night, day, or color vision was reported by 23 (72%), 22 (69%), and 18 (56%) patients, respectively. CONCLUSIONS: This study is limited by the large variability in follow-up time. There were no persistent statistically significant vision changes. A decrease in foveal thickness was noted in most eyes, but the long-term significance of this remains to be determined.

Multimorbidity patterns and their relationship to mortality in the US older adult population.

BACKGROUND: Understanding patterns of multimorbidity in the US older adult population and their relationship with mortality is important for reducing healthcare utilization and improving health. Previous investigations measured multimorbidity as counts of conditions rather than specific combination of conditions. METHODS: This cross-sectional study with longitudinal mortality follow-up employed latent class analysis (LCA) to develop clinically meaningful subgroups of participants aged 50 and older with different combinations of 13 chronic conditions from the National Health Interview Survey 2002-2014. Mortality linkage with National Death Index was performed through December 2015 for 166,126 participants. Survival analyses were conducted to assess the relationships between LCA classes and all-cause mortality and cause specific mortalities. RESULTS: LCA identified five multimorbidity groups with primary characteristics: "healthy" (51.5%), "age-associated chronic conditions" (33.6%), "respiratory conditions" (7.3%), "cognitively impaired" (4.3%) and "complex cardiometabolic" (3.2%). Covariate-adjusted survival analysis indicated "complex cardiometabolic" class had the highest mortality with a Hazard Ratio (HR) of 5.30, 99.5% CI [4.52, 6.22]; followed by "cognitively impaired" class (3.34 [2.93, 3.81]); "respiratory condition" class (2.14 [1.87, 2.46]); and "age-associated chronic conditions" class (1.81 [1.66, 1.98]). Patterns of multimorbidity classes were strongly associated with the primary underlying cause of death. The "cognitively impaired" class reported similar number of conditions compared to the "respiratory condition" class but had significantly higher mortality (3.8 vs 3.7 conditions, HR = 1.56 [1.32, 1.85]). CONCLUSION: We demonstrated that LCA method is effective in classifying clinically meaningful multimorbidity subgroup. Specific combinations of conditions including cognitive impairment and depressive symptoms have a substantial detrimental impact on the mortality of older adults. The numbers of chronic conditions experienced by older adults is not always proportional to mortality risk. Our findings provide valuable information for identifying high risk older adults with multimorbidity to facilitate early intervention to treat chronic conditions and reduce mortality.

Analysis of Socioeconomic Factors Affecting Follow-Up in a Glaucoma Screening Program.

PURPOSE: To determine what socioeconomic factors affect follow-up in a glaucoma screening program. PATIENTS AND METHODS: This was a retrospective cohort study of six health fairs in South Florida from October 2012 to March 2013 among socially and economically disadvantaged populations. Visual acuity (VA), intraocular pressure (IOP), cup-to-disc ratio (CDR), and visual field testing were obtained to identify glaucoma suspects. Glaucoma suspects were defined as having intraocular pressure ≥24 mm Hg, cup-to-disc ratio of ≥0.6 in either eye, or glaucomatous defects on visual field testing. In July 2015, telephone surveys were administered to assess follow up and socioeconomic factors. RESULTS: Seventy-two out of 144 (50%) glaucoma suspects responded to the survey and were included in the analysis. Of the 72 respondents, average age was 52.8 years old and 65% were female. The most common race was African American (69%) and ethnicity was Haitian (51%). Glaucoma suspects who followed up were significantly more likely to have health insurance compared to those who did not follow up (74% vs 43%, p = 0.014). No significant difference in follow-up based on age (p = 0.125), education (p = 0.151), gender (p = 0.48), or ethnicity (p = 0.707) was identified. Of the 30 respondents, who did not follow up, the most common reasons were "no insurance" (57%, 17/30) and "not worried" (33%, 10/30). CONCLUSION: Insurance was the main socioeconomic factor in determining whether glaucoma suspects followed up after community health screenings. Streamlining social services could increase clinical access of glaucoma suspects.

Chronic condition patterns in the US population and their association with health related quality of life.

This study aims to identify chronic disease patterns and their relationship to health-related quality of life (HRQL) in the US population. This cross-sectional study used data from 86,745 participants aged 18 years and older of the Medical Expenditure Panel Survey (MEPS) 2010-2015, we employed latent class analysis (LCA) to identify subgroups of participants with different combinations of 23 chronic conditions which had medical utilization during the past 12 months. Derived chronic condition latent classes were used to predict the 12-Item Short Form Survey physical component score (PCS), mental component score (MCS) in addition to overall HRQL (SF-6D) while controlling for covariates. LCA identified five unique multi-morbidity groups: "healthy" (62.5%), "vascular risk" (18.9%), "anxiety" (12.2%), "heart disease" (2.9%), and "severely-impaired" (3.5%). Covariate-adjusted mean SF-6D scores varied significantly among classes: healthy (0.85), vascular risk (0.77), anxiety (0.67), heart disease group (0.65), and severely-impaired (0.56). The anxiety group, proportionately younger and female, had high PCS (46.3) but low MCS (41.9). The heart disease group, although older and in poor physical health (PCS = 33.2), had higher MCS scores (46.9). Our results demonstrate multi-morbidity significantly impacts HRQL. The relationship between physical and mental health functioning varied across different multi-morbidity groups, and the discordance was more pronounced in younger ages and females. Our research also identified an older age group that was mentally robust and maintained a strong HRQL. Findings can inform the development of targeted interventions to improve physical and mental health functioning in vulnerable populations.

Patterns of Chronic Conditions and Their Association With Visual Impairment and Health Care Use.

Importance: Visual impairment and visual disorders often co-occur with other chronic conditions. Understanding patterns of multimorbidity is important for reducing health care use and improving health outcomes. Objective: To identify chronic condition patterns and their association with visual impairment and health care use in a nationally representative sample. Design, Setting, and Participants: This cross-sectional study used National Health Interview Survey data for 387 780 individuals aged 18 years and older, representative of the civilian noninstitutionalized US population, from January 1, 2002, to December 31, 2014. Statistical analysis was performed from June to November 2018. Exposures: Participants were classified in subgroups with different combinations of self-reported chronic conditions using latent class analysis. Main Outcomes and Measures: Self-reported visual impairment, emergency department visit, and hospitalization use in the previous 12 months. Results: Among the 387 780 individuals included in the study, 51.8% were female, 77.6% were white, and the mean (SD) age was 46.2 (18.0) years. Latent class analysis identified 5 different classes, with 70.5% of the participants belonging to the healthy group. The other 4 groups represented various degrees and patterns of multimorbidity. The hypertensive group (19.6%) had a high prevalence of hypertension (62.6%), the respiratory conditions group (4.4%) had a high prevalence of emphysema (47.7%) and asthma (45.6%), the heart disease group (3.6%) had high prevalence of coronary heart disease (69.8%), and the severely impaired group (1.8%) had higher prevalence of most conditions compared with the other groups. In the adjusted analysis, compared with the healthy group, participants in all 4 disease groups had elevated risk of visual impairment: heart condition group (odds ratio [OR], 3.19; 95% CI, 2.92-3.48), hypertensive group (OR, 3.28; 95% CI, 3.10-3.48), respiratory condition group (OR, 3.87; 95% CI, 3.56-4.20), and severely impaired group (OR, 10.19; 95% CI, 9.20-11.28). All 4 disease groups had elevated risk of reporting emergency department use and hospitalization. For the severely impaired group, the OR for emergency department use was 9.39 (95% CI, 8.53-10.34), and the OR for hospitalization was 10.80 (95% CI, 9.80-11.92). Conclusions and Relevance: In this study, individuals in all 4 multimorbidity groups had an elevated risk of visual impairment and health care use compared with the healthy group. Characteristics of high-risk groups identified by this study may help in the development and implementation of interventions to avert the more serious consequences of having multiple chronic conditions.

Longitudinal Associations Between Visual Impairment and Cognitive Functioning: The Salisbury Eye Evaluation Study.

Importance: Worsening vision and declining cognitive functioning are common conditions among elderly individuals. Understanding the association between them could be beneficial in mitigating age-related cognitive changes. Objective: To evaluate the longitudinal associations between visual impairment and cognitive function over time in a population-based study of older US adults. Design, Setting, and Participants: Prospective longitudinal population-based study of older adults in the greater Salisbury area in Maryland. Overall, 2520 community-residing adults aged 65 to 84 years were assessed at baseline between September 1993 and August 1995 (round 1) and 2 (round 2), 6 (round 3), and 8 (round 4) years later. Main Outcomes and Measures: Visual acuity (VA) was measured using Early Treatment Diabetic Retinopathy Study charts, and cognitive status was assessed using the Mini-Mental State Examination (MMSE). Results: Of 2520 individuals, the mean (SD) age was 73.5 (5.1) years, 1458 (58%) were women, and 666 (26%) were black. There were 2240 (89%), 1504 (61%), and 1250 (50%) participants in the second, third, and fourth round of study, respectively, with more than half of the loss being due to death. Both VA and MMSE score worsened over time. The mean biannual decline of VA was 0.022 logMAR (approximately 1 line during 8 years; 95% CI, 0.018-0.026), and the mean biannual worsening of MMSE score was -0.59 (95% CI, -0.64 to -0.54; both P < .001). Worse baseline VA was associated with worse baseline MMSE score (r = -0.226; 95% CI, -0.291 to -0.16; P < .001). The rate of worsening VA was associated with the rate of declining MMSE score (r = -0.139; 95% CI, -0.261 to -0.017; P = .03). Cross-lagged models indicated VA in the previous round was associated with MMSE score in the subsequent round (ß = -0.995, P < .001), and MMSE score in the previous round was associated with VA in the following round (ß = -0.003, P < .001). However, the standardized effect size of VA on MMSE score (ß = -0.074; SE, 0.015; P < .001) is larger relative to the reverse effect (ß = -0.038; SE, 0.013; P < .001), demonstrating VA is likely the driving force in these dynamic associations. Conclusions and Relevance: In a population-based sample of older US adults, visual impairment measured at distance is associated with declining cognitive function both cross-sectionally and longitudinally over time with worsening vision having a stronger association with declining cognition than the reverse. Worsening vision in older adults may be adversely associated with future cognitive functioning. Maintaining good vision may be an important interventional strategy for mitigating age-related cognitive declines.

Factors Associated With Receipt of Radiation Therapy for Rectal Cancer.

PURPOSE: Appropriate treatment for cancer is vital to increasing the likelihood of survival; however, for rectal cancer, there are demonstrated disparities in receipt of treatment by race/ethnicity and socioeconomic status. We evaluated factors associated with receipt of appropriate radiation therapy for rectal cancer using data from the Florida Cancer Data System that had been previously enriched with detailed treatment information collected from a Centers for Disease Control and Prevention Comparative Effectiveness Research study. This treatment information is not routinely available in cancer registry data and represents a unique data resource. MATERIALS AND METHODS: Using multivariable regression, we evaluated factors associated with receiving radiation therapy among rectal cancer cases stage II/III. Our sample (n=403) included cases diagnosed in Florida in 2011 who were 18 years and older. Cases clinically staged as 0/I/IV were excluded. RESULTS: Older age (odds ratio=0.96; 95% confidence interval, 0.94-0.97), the presence of one or more comorbidities (0.61; 0.39-0.96), and receipt of surgical intervention (0.44; 0.22-0.90) were associated with lack of radiation. CONCLUSIONS: In this cohort of patients, sociodemographic factors such as race/ethnicity, insurance status, and socioeconomic status, did not influence the receipt of radiation. Further research is needed, however, to understand why aging, greater comorbidity, and having surgery present a barrier to radiation therapy, particularly given that it is a well-tolerated treatment in most patients.

Eye Health Knowledge and Eye Health Information Exposure Among Hispanic/Latino Individuals: Results From the Hispanic Community Health Study/Study of Latinos.

Importance: Routine eye care is important to maintaining eye health and preventing visual impairment. However, poor knowledge of ocular risk factors and disease as well as minimal exposure to eye health information may compromise adherence to eye care recommendations. Studies have shown that Hispanic/Latino people have poor eye care utilization, but little is known about their knowledge of eye health and exposure to eye health information. Objective: To examine factors associated with more eye health knowledge and greater exposure to eye health information among Hispanic/Latino people. Design, Setting, and Participants: This was a cross-sectional ocular study of 1235 participants living in the Miami, Florida, site of the Hispanic Community Health Study/Study of Latinos, a multisite epidemiologic study of disease prevalence and development among Hispanic/Latino people. Data were collected from October 1, 2011, through September 30, 2013, and data analyses were conducted between May 28, 2014, and March 18, 2015. Descriptive and multivariable regression analyses were performed for 3 ocular health care outcomes. Regression models were built sequentially, with variables conceptually grouped according to Andersen's Behavioral Model of Health Services Use and Behavioral Model for Vulnerable Populations. Main Outcomes and Measures: Ability to identify 8 factors on a general eye health knowledge scale and number of eye health information sources seen or heard about in the past 12 months. Results: Of the 1235 participants, 748 (73.4%) self-identified as being of Cuban descent and 407 (19.2%) self-identified as being from Central or South America, 478 (46.7%) were women and 757 (53.3%) were men, and the mean (SD) age was 53.6 (8.1) years. Participants with at least a high school degree or general educational development certificate had greater eye health knowledge (incidence rate ratio [IRR], 1.08; 95% CI, 1.01-1.15 and IRR, 1.11; 95% CI, 1.04-1.17, respectively) as did those with a higher mental health score on the Short Form 12-Item, version 2, Health Survey (IRR, 1.03; 95% CI, 1.01-1.04). Those with educational attainment beyond a high school degree or a general educational development certificate (IRR, 1.29; 95% CI, 1.07-1.54), those who were 60 years or older (IRR, 1.32; 95% CI, 1.06-1.63), and those with a household income in US dollars of $20 001 to $40 000 (IRR, 1.23; 95% CI, 1.05-1.44) or greater than $40 000 (IRR, 1.25; 95% CI, 0.98-1.59) were more likely to be exposed to at least 5 sources of eye health information in the past 12 months. Conclusions and Relevance: Among Hispanic/Latino people, age, educational level, income, and mental health may be important correlates of eye disease knowledge and eye health information exposure. These findings might be used to support the development of targeted interventions designed to improve eye health in this population.

Ocular screening adherence across Hispanic/Latino heritage groups with diabetes: results from the Ocular SOL ancillary to the Miami site of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

OBJECTIVE: The objective of this study was to examine the prevalence and correlates of ocular screening adherence among select Hispanics/Latinos living with diabetes. RESEARCH DESIGN AND METHODS: Data were obtained through an ancillary study of the Hispanic Community Health Study/Study of Latinos (Miami site). Participants included Hispanics/Latinos aged 40+ years who underwent a baseline examination/risk factor assessment (2008-2011) and then completed a survey on vision health/knowledge (conducted October 2011-September 2013; sample n=1235; diabetic subsample=264). The dependent variable was having a dilated eye examination within the past 12 months. Covariate candidate selection for entry into sequential multivariable logistic regression models was guided by Anderson's Behavioral Model of Health Services Use and the Behavioral Model for Vulnerable Populations. RESULTS: Participants aged 65+ were more likely to have dilated eye examinations (OR 2.62, 95% CI 1.22 to 5.60) compared with those aged 40-54 years. Participants less likely to have dilated examinations had a high school degree or general educational development (GED) (OR 0.30, 95% CI 0.10 to 0.96, compared to no degree) and those currently uninsured or never insured ((OR 0.34, 95% CI 0.14 to 0.83) and (OR 0.19, 95% CI 0.07 to 0.51)) compared to those currently insured. Participants who heard or saw something about eye health from two or more sources (eg, media outlets, doctor's office, relatives/friends) compared to those who reported no sources in the past 12 months were more likely to have a dilated eye examination (OR 2.82, 95% CI 1.26 to 6.28). CONCLUSIONS: Lack of health insurance is strongly associated with low screening uptake in Hispanics/Latinos living with diabetes. Health promotion strategies stressing the importance of annual dilated eye examinations and increasing sources of information on eye health are other potential strategies to increase screening uptake in Hispanics/Latinos.

Factors Associated With Ocular Health Care Utilization Among Hispanics/Latinos: Results From an Ancillary Study to the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

IMPORTANCE: Regular ocular care is critical to early detection and prevention of eye disease and associated morbidity and mortality; however, there have been relatively few studies of ocular health care utilization among Hispanics/Latinos of diverse backgrounds. OBJECTIVE: To examine factors associated with ocular health care utilization among Cuban, Central American, and South American Hispanics/Latinos in a cohort study. DESIGN, SETTING, AND PARTICIPANTS: An ancillary study to the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) evaluating ocular health, knowledge, risk factors, and health care use was conducted with 1235 HCHS/SOL participants (aged ≥40 years) at the Miami, Florida, study site. Data were collected from October 17, 2011, to September 30, 2013, and analyses were conducted from May 28, 2014, to March 18, 2015. Descriptive and multivariable logistic regression analyses were performed for 3 ocular health care outcomes. Regression models were built sequentially with variables conceptually grouped according to Andersen's Behavioral Model of Health Services Use. MAIN OUTCOMES AND MEASURES: Ever having an eye examination, having an eye examination performed within the past 2 years, and difficulty obtaining needed eye care in the past year. RESULTS: Of the 1235 participants, 478 were men and 757 were women, and they had a mean (SD) age of 53.6 (8.1) years. Those who never had insurance were less likely to have had an eye examination (with data reported as odds ratios [95% CIs]) ever, 0.19 (0.07-0.53) and in the past 2 years, 0.22 (0.15-0.33) and were more likely to have had difficulty obtaining needed eye care in the past year (3.72 [1.75-7.93]). Those with less than excellent or good self-rated eyesight were less likely to ever have had an eye examination (0.26 [0.12-0.56]) and more likely to have had difficulty obtaining care (3.00 [1.48-6.11]). Men were less likely to ever have had an eye examination (0.31 [0.18-0.53]). Older (55-64 years) Hispanics/Latinos (3.04 [1.47-6.31]) and those with a high school degree or general educational development certification (2.06 [1.02-4.13]) or higher levels of education (4.20 [2.12-8.30]) were more likely to ever have had an eye examination. Finally, those living in the United States for more than 15 years (0.42 [0.21-0.82]) were less likely to have had difficulty obtaining care. CONCLUSIONS AND RELEVANCE: Our findings suggest that increasing insurance coverage, decreasing the costs of care, and increasing the availability of care for Hispanics/Latinos with poor self-rated eyesight are relevant issues to address to improve ocular health care use among Hispanics/Latinos of diverse backgrounds.

Longitudinal relationships between visual acuity and severe depressive symptoms in older adults: the Salisbury Eye Evaluation study.

OBJECTIVES: To assess the longitudinal relationship between visual acuity (VA) and depressive symptoms (DSs) among older adults. METHODS: A population-based sample of 2520 white and black individuals aged 65-84 years in 1993--1995 was assessed at baseline and at two, six, and eight years later. Presenting and best-corrected VA was assessed using early treatment diabetic retinopathy study chart. DSs were assessed using the severe depression subscale of General Health Questionnaire 28. Latent growth curve models estimated VA and DS trajectories and age-adjusted associations between trajectories. RESULTS: Best-corrected logMAR VA worsened over time (slope = 0.026, intercept = 0.013, both p < 0.001). No change in DS over time was observed (slope = -0.001, p = 0.762; intercept = 1.180, p < 0.001). However, a small change in DS was observed in participants who completed all rounds (slope = 0.005, p = 0.015). Baseline VA levels correlated with baseline DS levels (r = 0.14, p < 0.001). Baseline DS was associated with best-corrected VA change (r = 0.17, p = 0.01). Baseline best-corrected VA was not associated with DS change (r = 0.017, p = 0.8). Best-corrected VA change was not significantly associated with DS change (r = -0.03, p = 0.7). DISCUSSION: DSs are significantly associated with VA cross-sectionally, and persons with higher baseline DS scores were more likely to experience worsening VA over time. The complex relationship between visual impairment and DS suggests the need for a continued effort to detect and treat both visual decline and severe DSs in a growing elderly population.

Longitudinal relationships among visual acuity, daily functional status, and mortality: the Salisbury Eye Evaluation Study.

IMPORTANCE: Determination of the mechanisms by which visual loss increases mortality risk is important for developing interventional strategies. OBJECTIVE: To evaluate the direct and indirect effects of loss of visual acuity (VA) on mortality risk through functional status changes among aging adults. DESIGN, SETTING, AND PARTICIPANTS: Prospective longitudinal study of a population-based sample of 2520 noninstitutionalized adults aged 65 to 84 years from September 16, 1993, through July 26, 2003, in the greater Salisbury area of Maryland. Participants underwent reassessment 2, 6, and 8 years after baseline. Mortality status was ascertained from linkage with the National Death Index through 2009. EXPOSURES: Results of VA testing and self-reported functional status based on activities of daily living (ADL) and instrumental ADL (IADL). MAIN OUTCOMES AND MEASURE: Mortality. RESULTS: Worse VA levels at baseline were associated with an increased the risk for mortality (hazard ratio [HR], 1.16 [95% CI, 1.04-1.28]; P < .01) through their effect on lower IADL levels at baseline. Declines in VA over time were associated with increased mortality risk (HR, 1.78 [95% CI, 1.27-2.51]; P < .001) by way of decreasing IADL levels over time. Participants experiencing the mean linear decline in VA of 1 letter on the Early Treatment Diabetic Retinopathy Study acuity chart per year are expected to have a 16% increase in mortality risk during the 8-year study exclusively through associated declines in IADL levels. CONCLUSIONS AND RELEVANCE: In this longitudinal study of older adults, VA loss adversely affected IADL levels, which subsequently increased the risk for mortality. Prevention of disabling ocular conditions, treatment of correctable visual impairment, and interventions designed to prevent the effect of visual impairment on IADL declines may all reduce mortality risk in aging adults.

Visual acuity and increased mortality: the role of allostatic load and functional status.

PURPOSE: Poor vision may detrimentally impact functional status and affect allostatic load (AL), a measure of cumulative physiological wear and tear on the body's regulatory systems. We examined the direct effects of visual acuity (VA) on mortality and its indirect effect on mortality through its impact on functional status and AL in older adults. METHODS: Data from 4981 participants (age ≥ 60 years) from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) with mortality linkage through 2006 were analyzed. Functional status was assessed by activities of daily living (ADL) and instrumental activities of daily living (IADL). The AL index was composed of 10 biomarkers: systolic and diastolic blood pressures, body mass index (BMI), glycosylated hemoglobin, total cholesterol, triglycerides, albumin, C-reactive protein, homocysteine, and creatinine clearance. Visual acuity was categorized as no (20/20-20/25), mild (20/30-20/40), moderate (20/50-20/80), or severe (≥20/200) visual impairment. Structural equation modeling using three mediating variables representing ADL, IADL, and AL examined the effects of VA on all-cause and cardiovascular disease (CVD)-related mortality. RESULTS: Adjusting for all covariates, a one-unit change in VA category increased mortality risk (hazard ratio [HR] = 1.17; 95% confidence interval [CI] 1.05, 1.32); IADL and AL predicted mortality (HR = 1.15; CI 1.10, 1.20 and HR = 1.13; CI 1.06, 1.20, respectively). Activities of daily living did not predict mortality (HR = 0.98; CI 0.91, 1.05). Worse VA was associated with increased AL (ß = 0.11; P = 0.013) and worse IADL (ß = 1.06; P < 0.001). Worse VA increased mortality risk indirectly through AL (HR = 1.01; CI 1.00, 1.03) and IADL (HR = 1.16; CI 1.09, 1.23). The total effect of VA on mortality including through IADL and AL was HR = 1.38 (CI 1.23, 1.54). Similar but slightly stronger patterns of association were found when examining CVD-related mortality, but not cancer-related mortality. CONCLUSIONS: Allostatic load and particularly IADL may function as mediators between VA impairment and mortality. Older adults with VA impairment could potentially benefit from interventions designed to prevent IADL functional status decline to reduce the risk of mortality.

Structural equation modeling: a framework for ocular and other medical sciences research.

Structural equation modeling (SEM) is a modeling framework that encompasses many types of statistical models and can accommodate a variety of estimation and testing methods. SEM has been used primarily in social sciences but is increasingly used in epidemiology, public health, and the medical sciences. SEM provides many advantages for the analysis of survey and clinical data, including the ability to model latent constructs that may not be directly observable. Another major feature is simultaneous estimation of parameters in systems of equations that may include mediated relationships, correlated dependent variables, and in some instances feedback relationships. SEM allows for the specification of theoretically holistic models because multiple and varied relationships may be estimated together in the same model. SEM has recently expanded by adding generalized linear modeling capabilities that include the simultaneous estimation of parameters of different functional form for outcomes with different distributions in the same model. Therefore, mortality modeling and other relevant health outcomes may be evaluated. Random effects estimation using latent variables has been advanced in the SEM literature and software. In addition, SEM software has increased estimation options. Therefore, modern SEM is quite general and includes model types frequently used by health researchers, including generalized linear modeling, mixed effects linear modeling, and population average modeling. This article does not present any new information. It is meant as an introduction to SEM and its uses in ocular and other health research.

Longitudinal relationships among visual acuity and tasks of everyday life: the Salisbury Eye Evaluation study.

PURPOSE: To study the relationships among visual and physical function trajectories of aging adults. METHODS: The community-based random sample consists of 2520 adults who were aged 65 to 84 years in 1993 to 1995 and reassessed 2, 6, and 8 years later. Presenting and best-corrected Early Treatment Diabetic Retinopathy Study visual acuity were obtained. Activities of daily living (ADLs) and instrumental ADLs (IADLs) were evaluated through survey instruments. Growth curve models were used to simultaneously estimate health trajectories and obtain associations among the trajectories while controlling for relevant covariates. RESULTS: Best-corrected acuity (logMAR) worsened by an average of 0.013 (∼1 letter) annually. ADL difficulties increased by 0.22 standard deviations (SD) and IADL difficulties increased by 0.28 SD annually. Controlling for demographic and health covariates, visual acuity rates of decline correlated with rates of increase in ADL difficulties (r = 0.15, P = 0.05) and IADL difficulties (r = 0.41, P < 0.001). Acuity loss was significantly related to increases in ADLs for men (b = 0.039, P < 0.01), but not for women (b = 0.001, P > 0.9). The direct effects of acuity loss were strongest for IADLs where a 1-unit decline in acuity (logMAR) was associated with a 0.067 SD increase in IADL difficulties (P < 0.001) at baseline, and a 1-unit acuity decline (logMAR) per year resulted in a 0.10 SD unit increase in the rate of change in IADL difficulties (P < 0.001) per year. CONCLUSIONS: Over time, increases in visual acuity loss were related to increased IADL difficulties in men and women and increases in ADL difficulties for men only. The findings support the importance of maintaining vision in older adults.