Self-Reported Driving Difficulty, Avoidance, and Negative Emotion With On-Road Driving Performance in Older Adults With Glaucoma.

PURPOSE: To investigate the relationship between self-perceived driving difficulty, driving avoidance, and negative emotion about driving with glaucoma severity and on-road driving performance. DESIGN: Cohort study. METHODS: Glaucoma patients (n = 111), aged 55 to 90 years, with mild, moderate, and advanced glaucoma in the better-eye based on the Glaucoma Staging System, and age-matched controls (n = 47) were recruited from a large tertiary academic center. Self-reported questionnaires were administered by a trained occupational therapist followed by a standardized on-road driving evaluation (pass vs "at-risk" score) with a masked and certified driving rehabilitation specialist. RESULTS: Compared to controls, glaucoma participants reported greater driving difficulty with as early as mild glaucoma (P = .0391) and negative emotion about driving starting with moderate glaucoma (P = .0042). Glaucoma participants reporting at least 1 driving difficulty and negative emotion had a 3.3-fold (adjusted odds ratio [OR] = 3.3; 95% CI = 1.24-8.52; P = .0163) and 4.2-fold (adjusted OR = 4.2; 95% CI = 1.5-12.2; P = .0078) greater odds, respectively, of an at-risk score on the on-road test. Self-reported driving difficulty in "difficult" conditions (P = .0019), rain (P = .0096), interstates (P = .0378), and high traffic (P = .0076), driving avoidance on sunny (P = .0065) and cloudy (P = .0043) days, and driving fewer days per week (P = .0329) were also associated with at-risk driving. CONCLUSIONS: Screening tools that assess self-perceived driving difficulty and driving avoidance in specific conditions, negative emotion about driving, and driving exposure may help identify unsafe drivers with glaucoma. Some of these drivers, particularly those with modest glaucoma, may benefit from a driving evaluation and early referral to resources that could enable them to continue driving safely and confidently.

Rate of Falls, Fear of Falling, and Avoidance of Activities At-Risk for Falls in Older Adults With Glaucoma.

PURPOSE: To determine the relationship between glaucoma severity and rate of falls, fear of falling, and avoidance of activities at-risk for falls. DESIGN: Cross-sectional study. METHODS: Patients with glaucoma (n = 138) 55 to 90 years of age with mild (n = 61), moderate (n = 54), or advanced (n = 23) glaucoma in the better eye based on the Glaucoma Staging System and age-matched control subjects (n = 50) were recruited from the Eye Clinics at Washington University, St. Louis, MO. Participants completed questionnaires regarding falls, the fear of falling, and the avoidance of activities at-risk for falls. RESULTS: Of the glaucoma participants, 36% reported ≥1 fall in the previous 12 months compared with 20% of control subjects (adjusted odds ratio [OR] 2.7 [95% confidence interval {CI} 1.18-6.17]; P = .018). Compared with control subjects, the mild glaucoma group trended toward a higher fall risk (adjusted OR 2.43 [95% CI 0.97-6.08]; P = .059) and the advanced group had the highest fall risk (adjusted OR 7.97 [95% CI 2.44-26.07]; P = .001). A greater risk of a high fear of falling and high avoidance of at-risk activities occurred at the moderate stage of glaucoma compared with control subjects (adjusted OR 4.66 [95% CI 1.24-17.49]; P = .023 and adjusted OR 4.49 [95% CI 1.34-15.05]; P = .015, respectively). CONCLUSIONS: Patient education, interventions, and appropriate referrals to minimize falls should be considered in older adults with early glaucoma and continue with advancing disease. Minimizing a patient's fall risk may decrease their fear of falling and avoidance of at-risk activities. Reducing falls, the fear of falling, and the avoidance of at-risk activities may lower morbidity and mortality and improve emotional and social well-being of patients with glaucoma. Am J Ophthalmol 2021;221:•••-•••. © 2021 Elsevier Inc. All rights reserved.

Equating Visual Function Scales to Facilitate Reporting of Medicare Functional G-Code Severity/Complexity Modifiers for Low-Vision Patients.

OBJECTIVE: To present a method of estimating and equating scales across functional assessment instruments that appropriately represents changes in a patient's functional ability and can be meaningfully mapped to changes in Medicare G-code severity modifiers. DESIGN: Previously published measures of patients' overall visual ability, estimated from low-vision patient responses to 7 different visual function rating scale questionnaires, are equated and mapped onto Medicare G-code severity modifiers. SETTING: Outpatient low-vision rehabilitation clinics. PARTICIPANTS: The analyses presented in this article were performed on raw or summarized low-vision patient ratings of visual function questionnaire (VFQ) items obtained from previously published research studies. INTERVENTIONS: Previously published visual ability measures from Rasch analysis of low-vision patient ratings of items in different VFQs (National Eye Institute Visual Functioning Questionnaire, Index of Visual Functioning, Activities of Daily Vision Scale, Visual Activities Questionnaire) were equated with the Activity Inventory (AI) scale. The 39 items in the Self-Report Assessment of Functional Visual Performance (SRAFVP) and the 48 items in the Veterans Affairs Low Vision Visual Functioning Questionnaire (VA LV VFQ) were paired with similar items in the AI in order to equate the scales. MAIN OUTCOME MEASURES: Tests using different observation methods and indicators cannot be directly compared on the same scale. All test results would have to be transformed to measures of the same functional ability variable on a common scale as described here, before a single measure could be estimated from the multiple measures. RESULTS: Bivariate regression analysis was performed to linearly transform the SRAFVP and VA LV VFQ item measures to the AI item measure scale. The nonlinear relationship between person measures of visual ability on a logit scale and item response raw scores was approximated with a logistic function, and the 2 regression coefficients were estimated for each of the 7 VFQs. These coefficients can be used with the logistic function to estimate functional ability on the same interval scale for each VFQ and for transforming raw VFQ responses to Medicare's G-code severity modifier categories. CONCLUSIONS: The principle of using equated interval scales allows for comparison across measurement instruments of low-vision functional status and outcomes, but can be applied to any area of rehabilitation.

Factors Affecting Readiness for Low Vision Interventions in Older Adults.

OBJECTIVE: We sought to identify factors that facilitate and inhibit readiness for low vision interventions in people with vision loss, conceptualized as readiness for change in the way they perform daily activities. METHOD: We conducted 10 semistructured interviews with older adults with low vision and analyzed the results using grounded theory concepts. RESULTS: Themes involving factors that facilitated change included desire to maintain or regain independence, positive attitude, and presence of formal social support. Themes related to barriers to change included limited knowledge of options and activity not a priority. Themes that acted as both barriers and facilitators were informal social support and community resources. CONCLUSION: This study provides insight into readiness to make changes in behavior and environment in older adults with vision loss. Study findings can help occupational therapy practitioners practice client-centered care more effectively and promote safe and satisfying daily living activity performance in this population.

Home lighting assessment for clients with low vision.

OBJECTIVE: The goal was to develop an objective, comprehensive, near-task home lighting assessment for older adults with low vision. METHOD: A home lighting assessment was developed and tested with older adults with low vision. Interrater and test-retest reliability studies were conducted. Clinical utility was assessed by occupational therapists with expertise in low vision rehabilitation. RESULTS: Interrater reliability was high (intraclass correlation coefficient [ICC] = .83-1.0). Test-retest reliability was moderate (ICC = .67). Responses to a Clinical Utility Feedback Form developed for this study indicated that the Home Environment Lighting Assessment (HELA) has strong clinical utility. CONCLUSION: The HELA provides a structured tool to describe the quantitative and qualitative aspects of home lighting environments where near tasks are performed and can be used to plan lighting interventions. The HELA has the potential to affect assessment and intervention practices of rehabilitation professionals in the area of low vision and improve near-task performance of people with low vision.

Differences in vision between clinic and home and the effect of lighting in older adults with and without glaucoma.

IMPORTANCE: Patients often report greater visual difficulties at home than expected from vision testing in the clinic. Such discordance may be owing to worse vision in the home than measured in clinic. OBJECTIVE: To compare vision measured between the clinic and home and evaluate factors, including lighting, associated with these differences. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study conducted from 2005-2009 involved 126 patients with glaucoma and 49 without glaucoma recruited from the Glaucoma and Comprehensive Eye Clinics at Washington University, St Louis, Missouri. Patients underwent clinic and home visits, were aged 55 to 90 years, were consecutively recruited, and met inclusion criteria for this study. A total of 166 eligible patients refused participation. EXPOSURE: Participants underwent clinic and home visits randomized to order of completion. At each visit, masked and certified examiners measured binocular distance visual acuity (DVA) with a nonbacklit chart, near visual acuity (NVA), contrast sensitivity (CS), CS with glare, and lighting. MAIN OUTCOMES AND MEASURES: Differences in vision between the clinic and home. RESULTS: The mean scores for all vision tests were significantly better in the clinic than home for participants with and without glaucoma (P < .05, matched-pair t tests). For DVA, 29% of participants with glaucoma read 2 or more lines better in the clinic than home and 39% with advanced glaucoma read 3 or more lines better. For the entire sample, 21% of participants read 2 or more lines better in the clinic than home for NVA and 49% read 2 or more triplets better in the clinic for CS with glare. Lighting was the most significant factor associated with differences in vision between the clinic and home for DVA, NVA, and CS with glare testing (P < .05, multiple regression model). Median home lighting was 4.3 times and 2.8 times lower than clinic lighting in areas tested for DVA and NVA, respectively. Home lighting was below that recommended in 85% or greater of participants. CONCLUSIONS AND RELEVANCE: Vision measured in the clinic is generally better than vision measured at home, with differences mainly owing to poor home lighting. Knowledge that vision discrepancies between patient report and clinical testing may be owing to home lighting may initiate clinician-patient discussions to optimize home lighting and improve the vision of older adults in their homes.

Responsiveness of the EQ-5D to the effects of low vision rehabilitation.

PURPOSE: This study is an evaluation of the responsiveness of preference-based outcome measures to the effects of low vision rehabilitation (LVR). It assesses LVR-related changes in EQ-5D utilities in patients who exhibit changes in Activity Inventory (AI) measures of visual ability. METHODS: Telephone interviews were conducted on 77 low-vision patients out of a total of 764 patients in the parent study of "usual care" in LVR. Activity Inventory results were filtered for each patient to include only goals and tasks that would be targeted by LVR. RESULTS: The EQ-5D utilities have weak correlations with all AI measures but correlate best with AI goal scores at baseline (r = 0.48). Baseline goal scores are approximately normally distributed for the AI, but EQ-5D utilities at baseline are skewed toward the ceiling (median, 0.77). Effect size for EQ-5D utility change scores from pre- to post-LVR was not significantly different from zero. The AI visual function ability change scores corresponded to a moderate effect size for all functional domains and a large effect size for visual ability measures estimated from AI goal ratings. CONCLUSIONS: This study found that the EQ-5D is unresponsive as an outcome measure for LVR and has poor sensitivity for discriminating low vision patients with different levels of ability.

Cognitive, visual, auditory, and emotional factors that affect participation in older adults.

OBJECTIVE: To determine whether changes in hearing, cognition, depression, and vision affect daily life participation and whether screening tests that identify problems could be used in the home. METHOD: Interviewers assessed presence of medical conditions, social class, distance acuity, cognition, hearing, depression, and participation using valid screening tools. Participation scores were subgrouped according to negative or positive results. Multiple regression analysis determined association of screening tests with participation. RESULTS: Eighty-eight older adults, ages 62-90, participated. Positive screening tests were found in 43% of participants for distance acuity, 9% for cognitive problems, 8% for depression, and 15% for hearing loss. Relationships were found among age, cognition, depression, and vision and participation. CONCLUSION: Mild levels of decreased vision, depression, and decreased cognition are associated with lower participation. These conditions can be screened by occupational therapists and managed to help older adults remain active and maintain their health.

Screening patients with stroke for rehabilitation needs: validation of the post-stroke rehabilitation guidelines.

BACKGROUND: The authors assessed patients with acute stroke to determine whether the systematic use of brief screening measures would more efficiently detect cognitive and sensory impairment than standard clinical practice. METHODS: Fifty-three patients admitted to an acute stroke unit were assessed within 10 days of stroke onset. Performance on the screening measures was compared to information obtained from review of the patient's chart at discharge. Cognition, language, visual acuity, visual-spatial neglect, hearing, and depression were evaluated. RESULTS: Formal screening detected significantly more impairments than were noted in patient charts in every domain. Only 3 patients had no impairments identified on screening; all remaining patients had at least 1 impairment detected by screening that was not documented in the chart. Thirty-five percent had 3 or more undetected impairments. Memory impairment was most likely to be noted in the chart; for all other domains tested, undocumented impairment ranged from 61% (neglect) to 97% (anomia). CONCLUSION: Many acute stroke patients had cognitive and perceptual deficits that were not documented in their charts. These data support the Post-Stroke Rehabilitation Guidelines for systematic assessment even when deficits are not immediately apparent. Systematic screening may improve discharge planning, rehabilitation treatment, and long-term outcome of persons with stroke.