Screening for Visual Impairment in Older Adults: Systematic Review to Update the 1996 U.S. Preventiv

Author by : Roger Chou
Languange Used : en
Release Date : 2009
Publisher by :

ISBN :

Description : BACKGROUND: Impaired visual acuity is common in older adults. Screening for impaired visual acuity in primary care settings could identify older adults who are unaware of or do not report vision problems, and lead to interventions to improve vision, function and quality of life. PURPOSE: To assess the effects of screening for impaired visual acuity in primary care settings in older (age> 65 years) adults. DATA SOURCES: We searched the Cochrane Controlled Trials Registry and Cochrane Database of Systematic Reviews (through 3rd Quarter 2008) and MEDLINE database (1996 - July 2008) for relevant studies and meta-analyses. We supplemented electronic searches with reviews of reference lists of relevant articles and solicited additional citations from experts. STUDY SELECTION: We selected randomized trials and controlled observational studies that directly evaluated screening for impaired visual acuity in older adults. To evaluate indirect evidence on screening, we also included studies evaluating the diagnostic accuracy of screening tests for impaired visual acuity used in primary care settings, and randomized trials and controlled observational studies of treatments for impaired visual acuity due to refractive errors, cataracts, and age-related macular degeneration that reported clinical outcomes (visual acuity, quality of life, functional capacity, adverse events, or mortality). DATA EXTRACTION: One investigator abstracted data and a second investigator checked data abstraction for accuracy. Two investigators independently assessed study quality using methods developed by the United States Preventive Services Task Force. DATA SYNTHESIS (RESULTS): Direct evidence from three fair-quality cluster randomized trials (N=4,728) found vision screening as part of multi-component primary care intervention associated with no benefits compared to usual care, delayed screening, or no screening on visual acuity or other clinical outcomes. One randomized controlled trial found vision screening by an ophthalmologist in frail older adults associated with an increased risk of falls (relative risk 1.57, 95% CI 1.20 to 2.05) and a trend towards increased risk of fractures (relative risk 1.74, 95% CI 0.97 to 3.11). No other trial evaluated harms associated with screening, and no studies evaluated optimal screening intervals. Four studies found screening questions associated with low accuracy compared to visual acuity testing or an ophthalmologic examination for identification of vision impairment and four studies found visual acuity testing associated with low accuracy compared to an ophthalmologic examination for identification of any visual condition. Evidence on the diagnostic accuracy of the Amsler grid is limited to one study, and no studies evaluated diagnostic accuracy or utility of fundoscopic examination in primary care settings. A large population-based study found that about 60% of older adults with vision impairment could achieve visual acuity of 20/40 or better with refractive correction. Based on numerous observational studies, over 90% of patients undergoing cataract surgery achieve visual acuity of 20/40 or better. Antioxidant vitamins and minerals are more effective than placebo for reducing progression of dry age-related macular degeneration (adjusted odds ratio 0.68, 99% CI 0.49 to 0.93), though conclusions are largely influenced by results of a single, large, good-quality trial. For wet age-related macular degeneration, laser photocoagulation (relative risk 0.67 for 6+ lines visual acuity loss; 95% CI 0.53 to 0.83, five trials), photodynamic therapy (relative risk 0.22 for 3+ lines visual acuity loss, 95% CI 0.13 to 0.30, three trials), and vascular endothelin growth factor inhibitors (for 3+ lines visual acuity loss: pegaptanib [two trials] relative risk 0.71, 95% CI 0.61 to 0.84; ranibizumab [two trials] relative risk 0.21, 95% CI 0.16 to 0.27) are superior to placebo for prevention of visual acuity loss, though evidence on laser photocoagulation is limited by methodological shortcomings. Harms of commonly used interventions for uncorrected refractive error, cataract, and age-related macular degeneration appear to be substantially outweighed by benefits, though data on long-term benefits and harms of photodynamic therapy and vascular endothelin growth factor inhibitors are limited. LIMITATIONS: We excluded non-English language studies, could not evaluate for publication bias because of small numbers of trials, included previously published systematic reviews on treatments that met quality threshold criteria, and did not construct outcomes tables. CONCLUSIONS: Direct evidence is relatively limited, but shows that screening for impaired visual acuity in older adults in primary care settings is not associated with improved visual or other clinical outcomes and may be associated with unintended harms such as increased risk of falls. Effective treatments (benefits outweigh harms) are available for uncorrected refractive error, cataracts, and age-related macular degeneration. The Snellen chart is the standard for screening for impaired visual acuity in primary care, but its diagnostic accuracy is difficult to assess because a clinically relevant reference standard is not established. There remains no evidence on accuracy of fundoscopic examination by primary care providers. More research is needed to understand why the direct evidence on vision screening in older adults shows no benefit, despite the availability of effective treatments for common conditions associated with impaired visual acuity....

Author by : U. S. Department of Health and Human Services
Languange Used : en
Release Date : 2013-06-18
Publisher by : Createspace Independent Pub

ISBN :

Description : Impaired visual acuity is common in older adults. In addition to a higher incidence and prevalence of primary ocular disease and systemic diseases associated with ocular disease in older compared to younger adults, older adults also experience normal age-related changes in vision. Because symptoms may be relatively mild or progress slowly, older adults may be unaware of or underreport impaired visual acuity. Older adults may also have difficulty recognizing or reporting impaired visual acuity due to the presence of co-morbidities such as cognitive impairment. Screening for vision disorders could help identify impaired visual acuity in older adults and lead to treatments that improve quality of life or functional capacity, or prevent or slow down progression of vision loss. In 2008, the U.S. Preventive Services Task Force commissioned an evidence review on screening for impaired visual acuity in older adults, in order to inform an updated USPSTF guideline. The main purpose of the evidence review is to evaluate new evidence published on screening for impaired visual acuity in older adults. Impaired visual acuity refers to decreased clarity or sharpness of vision. In addition to decreased visual acuity, vision impairment can also be associated with decreases in low light vision, color vision, binocularity, contrast sensitivity, or stereopsis, as well as visual field loss (areas in the field of view in which objects cannot be seen). Visual acuity is most commonly assessed using the Snellen eye chart, which assesses the ability of patients to recognize letters of different sizes arranged in rows from a pre-specified distance (typically 20 feet). The severity of decreased visual acuity varies. Vision impairment has been defined as visual acuity of worse than 20/40 or 20/50 but better than 20/200 (the threshold for legal blindness). In this report, we use the term “impaired visual acuity” rather than “vision impairment” because the latter term implies functional limitations. In addition, vision impairment could occur for reasons other than visual acuity loss. Visual acuity worse than 20/20 but better than 20/40 or 20/50 is thought to have minimal effects on reading ability, functional capacity, or quality of life. Although no standardized definition for “mild” impairment in visual acuity exists, some studies have used a definition of visual acuity between roughly 20/40 and 20/80.This degree of impaired visual acuity is less likely to cause major functional limitations than more severe impairment in visual acuity, and may be more apt to be identified through screening. This report focuses on impaired visual acuity associated with the following conditions: uncorrected refractive errors, cataracts, and age-related macular degeneration (ARMD). Diabetic retinopathy and glaucoma are addressed elsewhere by the USPSTF. Screening approaches for glaucoma differ from the screening tests typically used in primary care settings for the conditions included in this report. Screening for diabetic retinopathy typically occurs in the context of care for patients with known diabetes. The KQs are: KQ1: Does vision screening in asymptomatic older adults result in improved morbidity or mortality or improved quality of life? KQ2: Are there harms of vision screening in asymptomatic older adults? KQ3: What is the accuracy of screening for early impairment in visual acuity due to uncorrected refractive error, cataracts or age-related macular degeneration? KQ4: Does treatment of early impairment in visual acuity due to uncorrected refractive error, cataracts or age-related macular degeneration lead to improved morbidity/mortality, or quality of life? KQ5: Are there harms of treating early impairment in visual acuity due to uncorrected refractive error, cataracts or age-related macular degeneration?...

Author by : U. S. Department of Health and Human Services
Languange Used : en
Release Date : 2013-05-11
Publisher by : Createspace Independent Pub

ISBN :

Description : This review was undertaken to support the U.S Preventive Services Task Force (USPSTF) in updating its 1996 recommendation on prevention of falls in older adults, which was part of its general review on household and recreational injuries. The 1996 USPSTF review found sufficient evidence that certain interventions reduce the risk for falls. This review found insufficient evidence, however, that counseling could be generalized to the primary care setting or that counseling reduced fall risk factors or the incidence of falls. The USPSTF also found insufficient evidence to recommend for or against the routine use of external hip protectors to prevent fall injuries. Issues requiring rectification for the USPSTF to change its recommendations include evidence showing that: primary care feasible interventions reduce the risk for falls or fall-related injuries in high-risk older adults; the general population benefits from these interventions; primary care counseling reduces the incidence of falling or fall-related injuries; primary care counseling is effective in encouraging older adults to increase their physical activity levels; and screening (balance and gait, visual acuity, ophthalmoscopic exam, dementia or altered mental status) reduces incidence of falls or fall-related injuries. A fall is “an unexpected event in which the participant comes to rest on the ground, floor, or lower level.” Because no single definition for a fall was consistently used across studies, we use the definition of a fall used by each reviewed study to maximize the number of included studies in the current review. People aged 65 years and older represent the fastest-growing segment of the U.S. population. Falls are associated with many adverse health outcomes, including injury and death. In 2003, the Centers for Disease Control and Prevention reported that falls were the leading cause of injury deaths, and the ninth leading cause of death from all causes, among those 65 years of age and older. Falls and fall-related injuries increase with age. Hip fractures are an especially grave complication of falls in older adults, resulting in more hospital admissions than any other injury. There is a 10% to 20% reduction in expected survival during the first year following a hip fracture, and roughly half of the survivors never recover normal function. Falls also predict quality of life and disability. Twenty to 30% of those who fall suffer injuries that result in decreased mobility that limits subsequent independence. Even falls that do not result in injury can lead to negative outcomes. In particular, experiencing a fall can increase an older person's fear of falling, an important psychological outcome correlated with future falls. Fear of falling leads older adults with and without a history of falling to limit activities, which eventually increases fall risk through functional decline, deterioration in perceived health status, and increased risk for admission to institutional care. KQ 1: Is there direct evidence that primary care interventions reduce fall-related injury, improve quality of life, reduce disability, or reduce mortality when used alone or in combination to reduce falling in community-dwelling older adults? 1a. Do these interventions reduce injury, improve quality of life, reduce disability, or reduce mortality in older adults specifically identified as high risk for falls? KQ 2: Do primary care interventions used alone or in combination in community-dwelling older adults prevent falling? 2a. Do these interventions prevent falling in older adults specifically identified as high risk for falls? 2b. Are there positive outcomes other than reduced falling, and related morbidity and mortality, that result from primary care interventions to prevent falling? KQ 3: What are the adverse effects associated with interventions to prevent falling? KQ 4: How are high-risk older adults identified for primary care interventions to prevent falling?...

Author by : National Academies of Sciences, Engineering, and Medicine
Languange Used : en
Release Date : 2017-01-15
Publisher by : National Academies Press

ISBN :

Description : The ability to see deeply affects how human beings perceive and interpret the world around them. For most people, eyesight is part of everyday communication, social activities, educational and professional pursuits, the care of others, and the maintenance of personal health, independence, and mobility. Functioning eyes and vision system can reduce an adult's risk of chronic health conditions, death, falls and injuries, social isolation, depression, and other psychological problems. In children, properly maintained eye and vision health contributes to a child's social development, academic achievement, and better health across the lifespan. The public generally recognizes its reliance on sight and fears its loss, but emphasis on eye and vision health, in general, has not been integrated into daily life to the same extent as other health promotion activities, such as teeth brushing; hand washing; physical and mental exercise; and various injury prevention behaviors. A larger population health approach is needed to engage a wide range of stakeholders in coordinated efforts that can sustain the scope of behavior change. The shaping of socioeconomic environments can eventually lead to new social norms that promote eye and vision health. Making Eye Health a Population Health Imperative: Vision for Tomorrow proposes a new population-centered framework to guide action and coordination among various, and sometimes competing, stakeholders in pursuit of improved eye and vision health and health equity in the United States. Building on the momentum of previous public health efforts, this report also introduces a model for action that highlights different levels of prevention activities across a range of stakeholders and provides specific examples of how population health strategies can be translated into cohesive areas for action at federal, state, and local levels....

Author by : Rainier P. Soriano
Languange Used : en
Release Date : 2007-05-26
Publisher by : Springer Science & Business Media

ISBN :

Description : This book distills the wealth of knowledge contained in the classic text, Geriatric Medicine: An Evidence-Based Approach, 4/e into a practical guide for primary care, family medicine, and internal medicine residents. Written by top experts in the field, the book offers a detailed, compact overview of geriatric care. It addresses geriatric pharmacology, Medicare and Medicaid, and numerous other subjects unique to older adults. The case-based instructional approach helps readers navigate the complexity of prevention, presentation, and treatment for conditions such as depression, dementia, and hypertension. Graphs and tables aid the reader in determining the proper courses of treatment....

Author by : Walter W Holland
Languange Used : en
Release Date : 2018-04-19
Publisher by : CRC Press

ISBN :

Description : Screening for disease has become a widely accepted concept in health care. Screening in Disease Prevention takes a critical look at the practice of screening throughout the various stages of life. The book highlights three current challenges: the increasing consumer, media and commercial focus on health in general and screening in particular; providing accurate and understandable information; and tackling the continuing variation in the uptake of screening between different areas of the country and different socio-economic groups. Screening in Disease Prevention is important reading for public health professionals, particularly those involved in screening programs. Policy makers and shapers, medical researchers, pressure groups and support organizations for people with screenable conditions will also find it a valuable reference....

Author by : Robert E. Rakel
Languange Used : en
Release Date : 2007-05
Publisher by : Elsevier Health Sciences

ISBN :

Description : This text has been admired for as long as Family Medicine has been a recognized specialty. Edited by the legendary Robert E. Rakel, MD, this superb 7th edition continues to break new ground. Includes materials to help hone your clinical skills and prepare for the ABFP boards and SPEX exams. Highlights especially important points of diagnosis and therapy in the case section of book. Provides Best Evidence Recommendations boxes to promote greater reliability of information. Offers a free CD-rom containing video clips of diabetes testing, stress test and all the illustrations from the book! Contains new chapters on complementary and alternative medicine. Takes a fresh new approach to evidence based medicine in clinical practice. Uses a visually appealing, functional 4-color design and a full-color insert....