What are the consequences of vision impairment within the elderly and how do you avoid further injuries obtained from a lack of awareness

1. The Consequences of Vision Impairment
for Older Adults
UCSD Geriatrics Symposium
April 13, 2019
Joshua R. Ehrlich, MD, MPH
Assistant Professor of Ophthalmology and Visual Sciences
Faculty Affiliate, Michigan Center on the Demography of Aging
University of Michigan

2. Financial disclosures
No conflicts of interest.
Grant Support
o National Eye Institute (K23EY027848)
o National Institute on Aging (P30AG012846, P30AG024824)
o U-M Pepper Center
o Michigan Center on the Demography of Aging
o Blue Cross Blue Shield of Michigan Foundation

3. Vision impairment and aging

4. Age related eye diseases
medicalgraphics.de. CC BY-ND 3.0
Glaucoma
Diabetic retinopathy
Macular degeneration
Cataract

5. Vision loss
National Institutes of Health. Public Domain.

7. Outline
I. Falls and vision
a. Epidemiology
b. Recent insights
c. Prevention
II. Cognitive decline and vision
a. Evidence
b. Theories
c. Recent developments

8. Vision Impairment and Falls
Effect Size

9. Vision Impairment and Fear of Falling
0%
10%
20%
30%
40%
50%
60%
AMD Glaucoma Fuchs Controls
Activity Restriction Due to FoF
(Wang 2012)
Wang MY, et al. Invest Ophthalmol Vis Sci. 2012. 53(13):7967-7972.

10. Prevalence of Falls in Older Adults with VI
Crews JE, et al. MMWR Morb Mortal Wkly Rep. 2016;65:433-437.
31%
59%
47%

11. What is prevalence of fall-related outcomes?
Data from NHATS 2011-2016
Self-Reported
• Vision: difficulty seeing at near or distance
• Falls: >1 fall in past year
• Fear of Falling: worry about falling and activity limitation in past month
• Balance: problems in past month

12. Prevalence of Fall-Related Outcomes in Older
Adults with Vision Impairment
*
* p<.001
*
*
0%
10%
20%
30%
40%
50%
60%
>1 Fall in Past
Year
Fear of Falling Fear of Falling
Limiting Activity
Balance
Problem
Any VI
No VI
*

13. Adjusted for: age, sex, race/ethnicity, education, Medicaid, medical comorbidities, and proxy
* p<.001
*
*
*
0%
10%
20%
30%
40%
50%
60%
>1 Fall in Past
Year
Fear of Falling Fear of Falling
Limiting Activity
Balance
Problem
Any VI
No VI
*
Adjusted Prevalence

14. • Significantly increased prevalence of falls and fall-related outcomes
in older adults with VI – even after adjustment for confounders
• But, no evidence-based interventions to decrease falls and fall-
related outcomes in this population
Ehrlich JR, et al. J Am Geriatr Soc. 2019;67:239-245.

15. Who falls and when do they fall?
Falls in Glaucoma (FIGS) Study
o Home is most common site of falls
o Risk of falls per step highest at home
o Worse glaucoma: higher risk per step in and out of home
o Injury more common with worse glaucoma
Ramulu PY, et al. Am J Ophthalmol. 2019. 200:169-178.
Sotimehin AE, et al. Am J Ophthalmol. 2018;192:131-141.
Yonge AV, et al. Ophthalmology. 2017;124:562-571.
thaigoodview.com. CC BY-SA-3.0

16. Preventing falls and fear of falling
o No evidence to guide interventions
Plausible interventions:
o Home modifications
o Early vision rehabilitation
o Balance and falls efficacy training
o RCTs and CER needed to determine what works and for whom
Tricco AC et al. J Am Med Assoc. 2017;318:1687-1699.
Virgili G and Rubin G. Cochrane Syst Rev. 2010.

17. For the primary care provider
o Regular eye exams
o most vision impairment is correctable or avoidable
o primary care plays an important role in eye care
o Communication with eye care provider
omobilize vision rehabilitation and OT services
o Falls efficacy and fall avoidance programs National Poll on Healthy Aging. healthyagingpoll.org

18. Vision and cognitive impairment
medicalgraphics.de. CC BY-ND 3.0

19. Vision and cognitive impairment
4% Good Vision Poor Vision
NASEM. Making Eye Health a Population Health Imperative. National Academies Press Press. 2016.
Rogers MA and Langa KM. Am J Epidemiol. 2010;171:728-735
Reyes-Ortiz CA, et al. J Am Geriatr Soc. 2005;681-686.

20. Cross-sectional data
o NHATS (2011-2015)
o 30,202 adults ≥ 65 years old
o Self-reported distance vision impairment: 1.9x increased odds of dementia
o Self-reported near vision impairment: 2.6x increased odds of dementia
o NHANES (1999-2002)
o 2,975 adults ≥ 60 years old
o Self-reported vision impairment: 2.7x increased odds of dementia
o Poor visual acuity: 2.8x increased odds dementia
Chen SP, et al. JAMA Ophthalmol. 2017;135(9):963-970.

21. Longitudinal data
o Salisbury Eye Evaluation
oLongitudinal, population-based study 2,520 adults 65-84 years old
o MMSE scores and visual acuity decline over time
o Rate of vision decline predicts rate of MMSE decline
Zheng DD, et al. JAMA Ophthalmol. 2018;136(9):989-995.

22. Longitudinal data
o Salisbury Eye Evaluation
oRate of vision decline predicts rate of MMSE decline
Zheng DD, et al. JAMA Ophthalmol. 2018;136(9):989-995.

23. Vision and cognitive impairment
Ehrlich JR, et al. Unpublished data.

24. Distance Vision Near Vision

25. Seeing dementia in the eyes
Systematic review of OCT in AD: 6 key measurements affected
• 30 studies, 1257 AD patients, 1460 controls
• The same metrics used clinically to monitor glaucoma
Chan VTT et al. Ophthalmology. 2019. 126:497-510.
Wies6014. CC-BY-SA-4.0

26. Hypotheses
NASEM. Making Eye Health a Population Health Imperative. National Academies Press Press. 2016.

27. Hypotheses
NASEM. Making Eye Health a Population Health Imperative. National Academies Press Press. 2016.

28. Sensory deprivation
o Cross-sectional associations of dementia with uncorrected refractive
error and presbyopia
o Poor vision associated with higher rate of incident dementia and
worsening dementia in large cohorts with different causes of vision loss
o Widespread loss of brain connectivity in blind – but can be reversed with
introduction of braille
Reyes-Ortiz CA, et al. J Am Geriatr Soc. 2005;681-686.
Jonas JB, et al. Sci Rep. 2018. 8:4816. Rogers MA and Langa KM. Am J Epidemiol. 2010;171:728-735.
Liu Y, et al. Brian. 2007;130(Pt 8):2085-2096. Zheng DD, et al. JAMA Ophthalmol. 2018;136(9):989-995.

29. Common cause
• Diabetic retinopathy: vascular
• Glaucoma: neurodegenerative
• Macular degeneration: neurodegenerative
• Dementia: vascular, neurodegenerative

30. Common cause: vascular dysfunction
Hutchins K. Acta Ophthalmol. 2018.96;e1031.
OptometrusPrime. CC-BY-SA-2.0
Wikipedia. Hirnarterien. CC-BY-SA-3.0
• Vascular dysfunction in AD and glaucoma
• glaucoma: reduced blood flow to optic nerve
• AD: vascular changes associated with dementia
• Patients with AD have changes in retinal blood
vessels

31. Common cause: neurotoxins
Gupta S and Aref AA. J Ophthalmic Vis Res. 2015.10(2):178-83
Yoneda S. Jpn J Ophthalmol. 2005.49:106-108.
Tau filaments
amyloid-β
PDB 2BEG. Bioinformatics
doi:10.1093/bioinformatics/bty419. RCSB PDB.
PDB 503T. Bioinformatics
doi:10.1093/bioinformatics/bty419). RCSB PDB.
• Higher Tau levels in vitreous in glaucoma and
diabetic retinopathy
• Abnormal Tau:
• Found in AD
• Found in advance but not early glaucoma

32. Common cause: the CSF
• Low CSF pressure in glaucoma and AD
• CSF circulatory failure may occur in glaucoma and AD
Gupta S and Aref AA. J Ophthalmic Vis Res. 2015.10(2):178-83.
Silverberg G et al. Cerebrospinal Fluid Res. 2006. 3:7.OpenStax. CC-BY-4.0

33. What about my patients?
• Eye exams
• Vision may be restored or progression halted
• Could this help slow cognitive decline?
• Vision rehabilitation
• Memory or Reasoning Enhanced Low Vision Rehabilitation
Whitson HE, et al. JAMA Ophthalmol. 2013. 131(7):912:919.

34. Future work in aging and vision
• Prospective data to determine causality
• Disaggregation of data to understand who is most affected
• Improved measurement to assess outcomes that matter to
patients
• RCTs and CER to determine what works and for whom

36. Thank you
o Diane Chau, MD
o Richard Bodor, MD
o Abigail Kumagai, BA
o Brian Stagg, MD, MS
o Chris Andrews, PhD
o Dave Musch, PhD, MPH
o Nish Patel, BA
o Shirin Hassan, BAppSc(Optom), PhD