1. MB Alzheimer Conference March 2007 VISION CARE SERVICES FOR THE PERSONAL CARE HOME RESIDENT Presented by: Dr. Pamela Hawranik Associate Professor University of Manitoba Sandy Bell RN BN MN Director Quality and Education Services Misericordia Health Centre

2. Vision Care Services History History Significance Significance Purpose Purpose

3. Vision Care Services Vision care services includes vision screening, vision assessment, referral and follow up of interventions. Vision care services includes vision screening, vision assessment, referral and follow up of interventions. PCH staff and families need to be educated on visual deficits and related care needs. PCH staff and families need to be educated on visual deficits and related care needs.

4. Lack of Access to Vision Care Services The issue of the lack of vision care services for residents living in a PCH setting is a global issue embedded in all types of health care systems, cultures and environments. The issue of the lack of vision care services for residents living in a PCH setting is a global issue embedded in all types of health care systems, cultures and environments. Australia, Iran, Great Britain, US, China and Canada all indicate this lack of service. Australia, Iran, Great Britain, US, China and Canada all indicate this lack of service.

5. Literature Review The current population in Canada over the age of 65 is 13% and is projected to increase to over 23% by the year 2030 (Statistics Canada, 2001) The current population in Canada over the age of 65 is 13% and is projected to increase to over 23% by the year 2030 (Statistics Canada, 2001) In Manitoba, 13. 6% of older adults are 65+, with over 8% residing in the PCH setting (Statistics Canada, 2001) In Manitoba, 13. 6% of older adults are 65+, with over 8% residing in the PCH setting (Statistics Canada, 2001) Research indicates that vision decline is directly related to the aging process (Houde & Huff, 2003) Research indicates that vision decline is directly related to the aging process (Houde & Huff, 2003)

6. Visual Deficits Cataracts Cataracts Refractive Errors Refractive Errors Macular Degeneration Macular Degeneration Glaucoma Glaucoma Diabetic Retinopathy Diabetic Retinopathy

7. These deficits contribute to falls, fractures, depression, increase in cognitive impairment and disruptive behaviors in the elderly ( Carnicelli, 2001) These deficits contribute to falls, fractures, depression, increase in cognitive impairment and disruptive behaviors in the elderly ( Carnicelli, 2001) Vision plays an important role in balance, mobility, falls, and standing balance of older persons Vision plays an important role in balance, mobility, falls, and standing balance of older persons Residents in the PCH setting who receive vision care services have demonstrated a DECREASE in these responses. Residents in the PCH setting who receive vision care services have demonstrated a DECREASE in these responses.

8. Exercise #1 Room Sweep Room Sweep Body Sway Body Sway

9. ■ Fall related hip fractures in the elderly are higher in persons with visual impairment (Brannan et al., 2003) ■ Falls are a major source of death and injury in the elderly. ■ Hip fractures are the most common fracture, the most devastating and the most costly to the health care system to treat (Kannus & Khan, 2001)

10. Administrators, physicians, nurses, residents, families and government are unaware of the effects that visual deficits have on the quality of life and independence of the elderly (Johnston, 2001) Administrators, physicians, nurses, residents, families and government are unaware of the effects that visual deficits have on the quality of life and independence of the elderly (Johnston, 2001) Health care is determined by assessing how much benefit is gained by a service in terms of life extension and/or improvement in quality of life. Vision care has not been viewed as medically necessary (National Advisory Council on Aging, 1995) Health care is determined by assessing how much benefit is gained by a service in terms of life extension and/or improvement in quality of life. Vision care has not been viewed as medically necessary (National Advisory Council on Aging, 1995)

11. Rates of eye disease and visual impairment among PCH residents is 3.3 times greater than any other segment of the population (Morer, 1994) Rates of eye disease and visual impairment among PCH residents is 3.3 times greater than any other segment of the population (Morer, 1994) Unrecognized visual impairment is a factor contributing to PCH placement and increased cognitive impairment Unrecognized visual impairment is a factor contributing to PCH placement and increased cognitive impairment (Van der Pols et al, 2000) (Van der Pols et al, 2000)

12. The Person with Alzheimer Disease Maintenance of visual acuity a key factor in the prevention of functional disability Maintenance of visual acuity a key factor in the prevention of functional disability Strong link between poor vision and ADL disability in PCH residents Strong link between poor vision and ADL disability in PCH residents Vision loss can be readily demonstrable in people with Alzheimer disease Vision loss can be readily demonstrable in people with Alzheimer disease

13. Residents with poor vision are more significantly dependent on caregivers for ADLs. Residents with poor vision are more significantly dependent on caregivers for ADLs. Visual impairment may exacerbate symptoms of dementia in patients with AD Visual impairment may exacerbate symptoms of dementia in patients with AD

14. Impaired face perception: may be traceable to deficits in contrast sensitivity Impaired face perception: may be traceable to deficits in contrast sensitivity Problems in spatial orientation and locomotion may be related to a deficit in depth perception Problems in spatial orientation and locomotion may be related to a deficit in depth perception Losses in central acuity have been associated with functional disability in PCH residents with AD Losses in central acuity have been associated with functional disability in PCH residents with AD

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

16. Vision Care Services for the Personal Care Home Resident: An Unmet Need Health Promotion Policy Vision Screening A Model of Intervention

17. Vision Screening Screening of disease is one method used to reduce health cost by ensuring that appropriate and timely health care is available for those in need Screening of disease is one method used to reduce health cost by ensuring that appropriate and timely health care is available for those in need Screening needs to include not only the assessment for disease indicators, but also accessibility for referral and treatment Screening needs to include not only the assessment for disease indicators, but also accessibility for referral and treatment Vision screening can be used to detect visual impairment not disease, with referral to appropriate eye care specialist Vision screening can be used to detect visual impairment not disease, with referral to appropriate eye care specialist

18. Feasibility of a Vision Screening Program in Manitoba Of the $819 million per year spent on unintentional injuries, $335 million is related to falls with $164 million devoted to treating falls among the elderly (Papadimitropoulos et al., 1997) Of the $819 million per year spent on unintentional injuries, $335 million is related to falls with $164 million devoted to treating falls among the elderly (Papadimitropoulos et al., 1997) In 2001, Seniors > 80 used 32% of all hospital days (Statistics Canada) In 2001, Seniors > 80 used 32% of all hospital days (Statistics Canada) It is estimated that 40% of falls leading to hospitalization are the results of hip fractures and that number will increase dramatically from 23,375 to over 88,000 cases by the year 2041 (Papadimitopoulos et al., 1997) It is estimated that 40% of falls leading to hospitalization are the results of hip fractures and that number will increase dramatically from 23,375 to over 88,000 cases by the year 2041 (Papadimitopoulos et al., 1997)

19. Feasibility (cont’d.) Manitoba is projected to have the second highest percent of visual impairment and blindness in Canada by 2026 (Statistics Canada, 2001) Manitoba is projected to have the second highest percent of visual impairment and blindness in Canada by 2026 (Statistics Canada, 2001) The average cost for a general vision examination in Manitoba is $50 - $70; cataract surgery is approximately $1200, and hip surgery required due to a fracture from a fall is upwards of $36,000 (Manitoba Health) The average cost for a general vision examination in Manitoba is $50 - $70; cataract surgery is approximately $1200, and hip surgery required due to a fracture from a fall is upwards of $36,000 (Manitoba Health) Based on these statistics and the foregoing discussion of literature, there is a need for a vision screening program in the Province of Manitoba Based on these statistics and the foregoing discussion of literature, there is a need for a vision screening program in the Province of Manitoba

20. Survey Questionnaires sent to 38 LTC facilities in Winnipeg Questionnaires sent to 38 LTC facilities in Winnipeg Purpose: Purpose: To determine whether routine vision care services are provided.To determine whether routine vision care services are provided.

21. MB Alzheimer Conference March 2007 Survey Results N= 28 LTC facilities responded N= 28 LTC facilities responded Facility size ranged from 60 to 240 beds Facility size ranged from 60 to 240 beds 1% to 8% of fractures were due to falls 1% to 8% of fractures were due to falls No data available that linked falls to vision impairment No data available that linked falls to vision impairment Falls per 1000 resident days, ranged from 5 to 30 Falls per 1000 resident days, ranged from 5 to 30

22. Survey Results (cont’d) 6 out of the 28 facilities indicated they provide vision care services upon admission 6 out of the 28 facilities indicated they provide vision care services upon admission Each identified a different action Each identified a different action 6 facilities indicated they had a policy on vision care services 6 facilities indicated they had a policy on vision care services 2 facilities had conducted an educational session on visual deficits during the past 6 months 2 facilities had conducted an educational session on visual deficits during the past 6 months

23. Need for more formalized vision care services in long term care facilities Need for more formalized vision care services in long term care facilities Need for staff to be aware of how to detect and care for persons with visual loss Need for staff to be aware of how to detect and care for persons with visual loss Need for staff to be aware of indicators of visual impairment in people with Alzheimer Disease Need for staff to be aware of indicators of visual impairment in people with Alzheimer Disease

24. Manitoba Health Falls Prevention Program Vision Care Vision Care Bone Health Bone Health Medications Medications

25. Our shared project “Focus on Falls Prevention” Misericordia Health Centre Misericordia Health Centre Misericordia Health Centre Foundation Misericordia Health Centre Foundation Manitoba Health Manitoba Health University of Manitoba University of Manitoba Manitoba Association of Optometrists Manitoba Association of Optometrists Canadian National Institute for the Blind Canadian National Institute for the Blind

26. PURPOSE To improve the Quality of Life for seniors in the Province of Manitoba To improve the Quality of Life for seniors in the Province of Manitoba To provide evidence to support improving vision in this population group will impact positively on falls and fractures and demonstrate a more positive outcome on the overall healthcare budget and wait times. To provide evidence to support improving vision in this population group will impact positively on falls and fractures and demonstrate a more positive outcome on the overall healthcare budget and wait times.

27. Pilot Project Pilot project 14 months. Commenced February, 2006 Pilot project 14 months. Commenced February, 2006 The intent of the pilot is to provide support for a Provincial Vision Screening Program for the Elderly who reside in the LTC and Community settings. The intent of the pilot is to provide support for a Provincial Vision Screening Program for the Elderly who reside in the LTC and Community settings.

28. Program Description Vision screening nurse provides on site vision screening Vision screening nurse provides on site vision screening On site optometry services On site optometry services Recommended interventions discussed with resident/ family Recommended interventions discussed with resident/ family Appropriate referrals Appropriate referrals Appropriate follow up Appropriate follow up Education Education

29. Characteristics 650 residents/ community screened 650 residents/ community screened Age Range: 59-101 Age Range: 59-101 Levels of Care in PCH : 2, 3, 4 Levels of Care in PCH : 2, 3, 4 Dementia: Dementia: PCH: 96%PCH: 96% Community: 10%Community: 10%

30. Results of Screening/Optometry Assessments PCH setting: PCH setting: All 500 residents screened exhibited some type of visual deficit. The vision screening tool was valid in all 500 assessmentsAll 500 residents screened exhibited some type of visual deficit. The vision screening tool was valid in all 500 assessments Undetected visual deficits: 450 Undetected visual deficits: 450 Community: Community: 150 vision screened. The vision screening tool was valid in all 150 assessments150 vision screened. The vision screening tool was valid in all 150 assessments Undetected visual deficits: 50Undetected visual deficits: 50

31. 20 residents dementia were not able to be screened utilizing the vision screening tool20 residents with dementia were not able to be screened utilizing the vision screening tool Strategies :Strategies : PCH: greater length of time for screening PCH: greater length of time for screening Community: More clients could read the smallest print and were faster in performing the test Community: More clients could read the smallest print and were faster in performing the test

32. Vision screening kit Relevant for screening people with Alzheimer Disease Relevant for screening people with Alzheimer Disease Residents receptive to tool Residents receptive to tool Specific strategies used Specific strategies used

33. Demonstration of Kit

34. Qualitative Case Study Results Man driving in the community Man driving in the community I CAN SEE I CAN SEE

35. Video Clip

36. Recommendations for Residents with AD 1. Label eyewear in appropriate resident populations with name and room number 2. Urge families to provide and extra pair of glasses in case of loss or damage 3. Ensure all residents have annual or biannual eye examinations.

37. Recommendations (cont’d) 4.Educate staff on visual deficits and care needs for residents with AD 5.Educate families on the effects of visual deficits and possible increase in cognitive, behavioral and functional issues

38. Next Steps Evaluate whether falls decrease Evaluate whether falls decrease Evaluate whether quality of life indicators improve Evaluate whether quality of life indicators improve Future study examining changes in people with Alzheimer Disease or related dementias Future study examining changes in people with Alzheimer Disease or related dementias

39. Questions ? Input ? Feedback ? Misericordia Health Centre Eye Care Centre of Excellence