MB Alzheimer ConferenceMB Alzheimer ConferenceMarch 2007March 2007

VISION CARE SERVICES FOR THE VISION CARE SERVICES FOR THE PERSONAL CARE HOME RESIDENTPERSONAL CARE HOME RESIDENT

Presented by:Presented by:

Dr. Pamela Hawranik Dr. Pamela Hawranik

Associate ProfessorAssociate Professor

University of ManitobaUniversity of Manitoba

Sandy Bell RN BN MNSandy Bell RN BN MN

Director Quality and Education ServicesDirector Quality and Education Services

Misericordia Health CentreMisericordia Health Centre

Vision Care ServicesVision Care Services

HistoryHistory

SignificanceSignificance

PurposePurpose

Vision Care ServicesVision Care Services

Vision care services includes vision Vision care services includes vision screening, vision assessment, screening, vision assessment, referral and follow up of referral and follow up of interventions.interventions.

PCH staff and families need to be PCH staff and families need to be educated on visual deficits and educated on visual deficits and related care needs.related care needs.

Lack of Access to Vision Care Lack of Access to Vision Care ServicesServices

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 setting is a global issue embedded in all types of health care systems, all types of health care systems, cultures and environments. cultures and environments.

Australia, Iran, Great Britain, US, Australia, Iran, Great Britain, US, China and Canada all indicate this China and Canada all indicate this lack of service.lack of service.

Literature ReviewLiterature Review

The current population in Canada over the The current population in Canada over the age of 65 is 13% and is projected to age of 65 is 13% and is projected to increase to over 23% by the year 2030 increase to over 23% by the year 2030 (Statistics Canada, 2001)(Statistics Canada, 2001)

In Manitoba, 13. 6% of older adults are In Manitoba, 13. 6% of older adults are 65+, with over 8% residing in the PCH 65+, with over 8% residing in the PCH setting setting (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 & Huff, 2003)(Houde & Huff, 2003)

Visual DeficitsVisual Deficits

CataractsCataracts

Refractive ErrorsRefractive Errors

Macular DegenerationMacular Degeneration

Glaucoma Glaucoma

Diabetic RetinopathyDiabetic Retinopathy

These deficits contribute to falls, fractures, These deficits contribute to falls, fractures, depression , increase in cognitive depression , increase in cognitive impairment and disruptive behaviors in impairment and disruptive behaviors in the elderly ( Carnicelli, 2001)the elderly ( Carnicelli, 2001)

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 personsolder persons

Residents in the PCH setting who receive Residents in the PCH setting who receive vision care services have demonstrated a vision care services have demonstrated a DECREASE in these responses.DECREASE in these responses.

Exercise #1Exercise #1

Room SweepRoom Sweep

Body SwayBody Sway

■ ■ Fall related hip fractures in the elderly are Fall related hip fractures in the elderly are

higher in persons with visual impairmenthigher in persons with visual impairment (Brannan et al., 2003)(Brannan et al., 2003)

■ ■ Falls are a major source of death and Falls are a major source of death and injury in the elderly. injury in the elderly.

■ ■ 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)

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 elderlyindependence of the elderly (Johnston, 2001)(Johnston, 2001)

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 necessaryviewed as medically necessary (National (National Advisory Council on Aging, 1995Advisory Council on Aging, 1995))

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

Unrecognized visual impairment is a Unrecognized visual impairment is a factor contributing to PCH placement factor contributing to PCH placement and increased cognitive impairmentand increased cognitive impairment

(Van der Pols et al, 2000)(Van der Pols et al, 2000)

The Person with Alzheimer Disease The Person with Alzheimer Disease

Maintenance of visual acuity a key Maintenance of visual acuity a key factor in the prevention of functional factor in the prevention of functional disabilitydisability

Strong link between poor vision and Strong link between poor vision and ADL disability in PCH residentsADL disability in PCH residents

Vision loss can be readily Vision loss can be readily demonstrable in people with demonstrable in people with Alzheimer diseaseAlzheimer disease

Residents with poor vision are more Residents with poor vision are more significantly dependent on caregivers significantly dependent on caregivers for ADLs.for ADLs.

Visual impairment may exacerbate Visual impairment may exacerbate symptoms of dementia in patients symptoms of dementia in patients with ADwith AD

Impaired face perception: may be Impaired face perception: may be traceable to deficits in contrast traceable to deficits in contrast sensitivitysensitivity

Problems in spatial orientation and Problems in spatial orientation and locomotion may be related to a locomotion may be related to a deficit in depth perceptiondeficit in depth perception

Losses in central acuity have been Losses in central acuity have been associated with functional disability associated with functional disability in PCH residents with ADin PCH residents with AD

Interventions can be EffectiveInterventions can be Effective

Simple refractory alterations and cataract Simple refractory alterations and cataract surgery can have an impact on falls, surgery can have an impact on falls, fractures and quality of life fractures and quality of life (Harwood et al., (Harwood et al., 2005)2005)

Vision Care Services for the Personal Care Home Resident:

An Unmet Need

Health PromotionPolicy

Vision Screening

A Model of Intervention

Vision ScreeningVision Screening Screening of disease is one method used to Screening of disease is one method used to

reduce health cost by ensuring that reduce health cost by ensuring that appropriate and timely health care is appropriate and timely health care is available for those in needavailable for those in need

Screening needs to include not only the Screening needs to include not only the assessment for disease indicators, but also assessment for disease indicators, but also accessibility for referral and treatmentaccessibility for referral and treatment

Vision screening can be used to detect visual Vision screening can be used to detect visual impairment not disease, with referral to impairment not disease, with referral to appropriate eye care specialistappropriate eye care specialist

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 (Papadimitropoulos et al., among the elderly (Papadimitropoulos et al., 1997)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 results of hip fractures hospitalization are the results of hip fractures and that number will increase dramatically from and that number will increase dramatically from 23,375 to over 88,000 cases by the year 2041 23,375 to over 88,000 cases by the year 2041 (Papadimitopoulos et al., 1997)(Papadimitopoulos et al., 1997)

Feasibility Feasibility (cont’d.)(cont’d.)

Manitoba is projected to have the second Manitoba is projected to have the second highest percent of visual impairment and highest percent of visual impairment and blindness in Canada by 2026 (Statistics Canada, blindness in Canada by 2026 (Statistics Canada, 2001)2001)

The average cost for a general vision The average cost for a general vision examination in Manitoba is $50 - $70; cataract examination in Manitoba is $50 - $70; cataract surgery is approximately $1200, and hip surgery surgery is approximately $1200, and hip surgery required due to a fracture from a fall is upwards required due to a fracture from a fall is upwards of $36,000 (Manitoba Health)of $36,000 (Manitoba Health)

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

SurveySurvey

Questionnaires sent to 38 LTC Questionnaires sent to 38 LTC facilities in Winnipegfacilities in Winnipeg

Purpose:Purpose:• To determine whether routine vision To determine whether routine vision

care services are provided.care services are provided.

MB Alzheimer ConferenceMB Alzheimer ConferenceMarch 2007March 2007

Survey ResultsSurvey Results

N= 28 LTC facilities respondedN= 28 LTC facilities responded

Facility size ranged from 60 to 240 bedsFacility size ranged from 60 to 240 beds

1% to 8% of fractures were due to falls1% to 8% of fractures were due to falls

No data available that linked falls to No data available that linked falls to vision impairmentvision impairment

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

Survey Results Survey Results (cont’d)(cont’d)

6 out of the 28 facilities indicated 6 out of the 28 facilities indicated they provide vision care services they provide vision care services upon admissionupon admission

Each identified a different actionEach identified a different action 6 facilities indicated they had a 6 facilities indicated they had a

policy on vision care servicespolicy on vision care services 2 facilities had conducted an 2 facilities had conducted an

educational session on visual deficits educational session on visual deficits during the past 6 monthsduring the past 6 months

Need for more formalized vision care Need for more formalized vision care services in long term care facilitiesservices in long term care facilities

Need for staff to be aware of how to Need for staff to be aware of how to detect and care for persons with detect and care for persons with visual lossvisual loss

Need for staff to be aware of Need for staff to be aware of indicators of visual impairment in indicators of visual impairment in people with Alzheimer Diseasepeople with Alzheimer Disease

Manitoba Health Falls Manitoba Health Falls Prevention ProgramPrevention Program

Vision CareVision Care Bone HealthBone Health

MedicationsMedications

Our shared projectOur shared project“Focus on Falls Prevention”“Focus on Falls Prevention”

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

PURPOSEPURPOSE

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

To provide evidence to support To provide evidence to support improving vision in this population improving vision in this population group will impact positively on falls group will impact positively on falls and fractures and demonstrate a and fractures and demonstrate a more positive outcome on the overall more positive outcome on the overall healthcare budget and wait times.healthcare budget and wait times.

Pilot ProjectPilot Project

Pilot project 14 months. Commenced Pilot project 14 months. Commenced February , 2006February , 2006

The intent of the pilot is to provide The intent of the pilot is to provide support for a Provincial Vision support for a Provincial Vision Screening Program for the Elderly Screening Program for the Elderly who reside in the LTC and who reside in the LTC and Community settings.Community settings.

Program DescriptionProgram Description

Vision screening nurse provides on Vision screening nurse provides on site vision screeningsite vision screening

On site optometry servicesOn site optometry services Recommended interventions Recommended interventions

discussed with resident/ familydiscussed with resident/ family Appropriate referrals Appropriate referrals Appropriate follow up Appropriate follow up Education Education

CharacteristicsCharacteristics

650 residents/ community screened650 residents/ community screened

Age Range: 59-101Age Range: 59-101

Levels of Care in PCH : 2, 3 , 4Levels of Care in PCH : 2, 3 , 4

Dementia: Dementia: • PCH: 96%PCH: 96%• Community: 10%Community: 10%

Results of Screening/Optometry Results of Screening/Optometry AssessmentsAssessments

PCH settingPCH setting::• All 500 residents screened exhibited some type All 500 residents screened exhibited some type

of visual deficit. The vision screening tool was of visual deficit. The vision screening tool was valid in all 500 assessmentsvalid in all 500 assessments

• Undetected visual deficits: 450Undetected visual deficits: 450 CommunityCommunity::

• 150 vision screened. The vision screening tool 150 vision screened. The vision screening tool was valid in all 150 assessmentswas valid in all 150 assessments

• Undetected visual deficits: 50 Undetected visual deficits: 50

• 20 residents 20 residents with dementia were not dementia were not able to be screened utilizing the vision able to be screened utilizing the vision screening toolscreening tool

• Strategies : Strategies : PCH: greater length of time for screeningPCH: greater length of time for screening Community: More clients could read the Community: More clients could read the

smallest print and were faster in performing smallest print and were faster in performing the testthe test

Vision screening kitVision screening kit

Relevant for screening people with Relevant for screening people with Alzheimer DiseaseAlzheimer Disease

Residents receptive to toolResidents receptive to tool

Specific strategies usedSpecific strategies used

Demonstration of KitDemonstration of Kit

Qualitative Case Study ResultsQualitative Case Study Results

Man driving in the communityMan driving in the community

I CAN SEEI CAN SEE

Video ClipVideo Clip

Recommendations for Recommendations for Residents with ADResidents with AD

1. Label eyewear in appropriate 1. Label eyewear in appropriate resident populations with name and resident populations with name and room numberroom number

2. Urge families to provide and extra 2. Urge families to provide and extra pair of glasses in case of loss or pair of glasses in case of loss or damagedamage

3. Ensure all residents have annual or 3. Ensure all residents have annual or biannual eye examinations.biannual eye examinations.

Recommendations (cont’d)Recommendations (cont’d)

4.4. Educate staff on visual deficits Educate staff on visual deficits and and care needs for residents with ADcare needs for residents with AD

5.5. Educate families on the effects Educate families on the effects of of visual deficits and possible visual deficits and possible increase in cognitive, behavioral increase in cognitive, behavioral and functional issuesand functional issues

Next StepsNext Steps

Evaluate whether falls decreaseEvaluate whether falls decrease Evaluate whether quality of life Evaluate whether quality of life

indicators improveindicators improve Future study examining changes in Future study examining changes in

people with Alzheimer Disease or people with Alzheimer Disease or related dementiasrelated dementias

Questions ?Questions ?Input ?Input ?

Feedback ?Feedback ?

Misericordia Health Centre

Eye Care Centre of Excellence