Consistent Vision Care is Beneficial in the Nursing Home Setting
Many ocular diseases, including glaucoma, cataracts, and the dry and wet forms of macular degeneration, become more prevalent with age and can lead to progressive vision loss. Despite these conditions being prevalent in geriatric patients, many long-term care (LTC) facilities are not equipped to adequately identify and address them. Yet leaving vision problems unidentified and untreated can have serious ramifications, including significantly reduced quality of life for residents. In 2012, Joseph Eichenbaum, MD, MPH, associate clinical professor of ophthalmology, Mount Sinai School of Medicine, New York, NY, published a review article in the Mount Sinai Journal of Medicine that examined different causes of geriatric vision loss and how to manage them (www.ncbi.nlm.nih.gov/pubmed/22499498). Annals of Long-Term Care® had the opportunity to discuss this report with Dr. Eichenbaum to obtain his insights on what can be done to improve vision care for LTC residents.
What are the implications of untreated visual impairment for the geriatric patient?
Dr. Eichenbaum: Numerous problems can occur, including driving accidents, depression, and hip fractures from an increased risk of falls. If someone has 100%, 80%, or even 66% of their vision and it drops to 30%, it can be distressing, as it becomes harder to do everyday things, from reading, to navigating, to putting a key in the door. Losing the ability to do routine everyday activities can cause a lot of frustration, while also increasing the odds of earlier nursing home placement.
What are some impediments to early diagnosis and treatment of vision problems in geriatric patients?
Although persons with visual impairments usually pipe up and say something, patient-related factors are the most common impediment to early diagnosis and treatment. Factors that prevent patients from seeking medical attention include denial, whether on the part of the patient and/or his or her caregiver; economic concerns; or depression. In addition, if a patient is living alone, he or she may have become accustomed to the situation, may not want to depend on others for help with activities of daily living, or may fear being placed into a nursing home. Finally, if a patient has dementia, he or she may be less able to communicate vision problems.
How does nursing home placement affect a patient’s screening and treatment of vision problems?
Nursing home providers might think that if a resident is not speaking up about a vision problem, it is not bothersome to him or her and does not warrant treatment. The presence of dementia may also reduce the odds that a resident will be screened or treated for vision problems, and it may also reduce the likelihood that more invasive treatments like cataract surgery will be performed. After all, if brain function is already compromised, re-establishing visual and cognitive connections may not be possible or may be perceived as offering little benefit; thus, undertaking surgery may not be deemed worth the risk.
Do you foresee the upcoming Medicare and health insurance changes impacting vision screenings and treatments, particularly among nursing home residents?
Potentially. If you do not permit nursing home residents to receive routine, ongoing vision care, many will not receive such care. In addition, the patients who are not taking their medications may not be identified, increasing the risk of continued decline. For example, not taking glaucoma medication may lead to loss of peripheral vision. If you shorten the exposure patients have to routine clinics because of reductions in Medicare-allowed visits, certain treatable conditions may be overlooked. For example, limiting coverage may prevent wet macular degeneration from being identified in dysphasic patients, resulting in a lost opportunity to treat acute progressive central vision loss with newer medicines that have recently been shown to be quite effective in saving central vision. In addition to hastening patients’ visual demise, there will be a cascade of negative effects, including the need for earlier and greater nursing care for feeding, bathing, and walking. There is also an increased risk of depression and of fractures attributable to poor vision and poor balance. This is just one scenario. That said, nothing definitive has been decided yet; therefore, if enough people—including individual and group healthcare providers—speak up for nursing homes and make demands for coverage beyond the very basics, such issues might be prevented. But until it is clear what part of the Medicare pie is going to be allotted to ongoing care in institutional settings, we can only speculate on what will happen and what the ramifications may be.
Are there nutritive strategies that can help with vision?
It depends on the underlying cause of the vision problem. For example, in 25% of cases, if patients have dry macular degeneration with geographic atrophy and medium to large drusen, the progression of their vision degeneration can be slowed with antioxidants (eg, vitamins A, C, E, zinc, and lutein) provided in regimented doses. Over-the-counter antioxidant formulations for vision are available, with PreserVision and ICaps being two examples. If nursing home residents can’t swallow these pills, nursing home staff may need to cut them open and add them to foods like applesauce. In addition, regular consumption of blueberries, blackberries, raspberries, broccoli, and spinach can also supply these antioxidants and thereby slow vision loss. Getting nutrients from food sources might be a safer option in a setting where polypharmacy is so prevalent.
In your article, you mentioned that some antioxidants (ie, vitamin A, vitamin E) may be associated with increased mortality risk. How can you determine which patients would benefit from receiving vitamin supplements and which would not?
A JAMA article was published a few years ago that examined what problems might arise with excess vitamin intake. For example, excess use of vitamin A by former smokers led to a higher risk of recurrent lung cancer, whereas an increased risk of prostate cancer was associated with high doses of vitamin E. These findings show that more is not always better, and before prescribing any vitamins to patients, clinicians need to carefully review the patient’s medical history and determine a threshold level of vitamin intake. Also, fat-soluble vitamins, particularly A, E, and K, have the greatest propensity to cause adverse effects. Unlike water-soluble vitamins, which are routinely excreted, these vitamins are stored by the liver and can quickly accumulate to reach toxic levels, especially in elders who already have a slow drug metabolism.
Are there any technologies that might be beneficial for LTC residents with vision impairments?
I’ve found handheld tablets, such as the iPad, Kindle, or Nook, to be one of the most helpful technologies. These devices enable letter magnification to be adjusted. Although they cost several hundred dollars, they can restore a patient’s access to familiar reading items, such as newspapers, magazines, and books. But many patients will have to learn how to read differently. For example, patients with dry macular degeneration in the 20/60 to 20/400 range have to keep looking around the screen because they have poor or no central vision; however, if the print can be adequately enlarged, they can determine the words and ideas. It is more of a vertical reading experience. Regardless, the ability to decipher what is on a page enables patients to continue as avid readers and can help prevent seclusion, depression, and dementia. The less “in touch” and less independent these patients become, the more likely they are to become isolated and depressed. Tablets and e-readers can help provide normal daily activity, while enabling patients to escape from the monotony of institutional life.
Dr. Eichenbaum reports no relevant financial relationships.
Preservative-Free Treatment for Elevated Intraocular Pressure
Open-angle glaucoma is the most common form of glaucoma, a disease that is the second leading cause of blindness in the United States. While glaucoma is a risk at any age, as a patient’s age increases, so does his or her risk of developing this disease. On February 10, 2012, the FDA approved tafluprost 0.0015% ophthalmic solution (Zioptan), a prostaglandin drop used to treat elevated eye pressure in patients with open-angle glaucoma or ocular hypertension. Ocular hypertension is generally considered to be an intraocular pressure reading >21 mm Hg and is a risk factor for glaucoma.
While numerous classes of medication are available to treat glaucoma, prostaglandin drops are often a first-line treatment for open-angle glaucoma because they are effective in lowering intraocular pressure and cause fewer adverse effects than other treatments, resulting in good compliance. Unlike other prostaglandins on the market, Zioptan does not contain a preservative. This formulation was introduced to reduce preservative-related side effects and improve patient compliance. Studies have shown this agent to be as efficacious as preservative-containing formulations, but to be more comfortable during long-term treatment and to offer improved compliance and tolerability, particularly among patients who experienced ocular surface damage after using other prostaglandin analogs. Reports have also shown Zioptan to produce less severe incidences of ocular hyperemia and to reduce incidences of irritation and itching.
Possible side effects of Zioptan include darkening of the iris, darkening of the eyelid, and eyelash growth. To access Zioptan’s full prescribing information visit www.merck.com/product/usa/pi_circulars/z/zioptan/zioptan_pi.pdf. To read a recently published literature review on tafluprost visit www.dovepress.com/tafluprost-once-daily-for-treatment-of-elevated-intraocular-pressure-i-peer-reviewed-article-OPTH.
Ophthalmic Drugs Should Factor Into the Polypharmacy Equation in Nursing Homes
The incidence of glaucoma increases with age, and with life expectancy on the rise, glaucoma is becoming more prevalent worldwide. Although a variety of glaucoma treatments are available, local pharmacotherapy (ie, glaucoma eye drops) is the primary treatment option, especially for elders. While glaucoma eye drops are generally considered safe, there may be associated systemic risks, particularly among frail nursing home residents who are receiving multiple medications. Because there are limited data about the use of ophthalmic drugs in combination with other medications, Matthias Huber, Institute of Clinical Pharmacology and Toxicology, Charite, Universitätsmedizin Berlin, Germany, and colleagues assessed prescribing practices for antiglaucoma agents among a group of German nursing home residents on polypharmacy regimens. Their findings were published in the January 2013 issue of Drugs and Aging (www.ncbi.nlm.nih.gov/pubmed/23184270).
Huber and colleagues’ study assessed the health insurance records of 8685 German nursing home residents aged 65 to 106 years. These residents collectively had 88,695 drug prescriptions, with the average resident receiving 6.0 ± 3.3 drugs. Of these patients, 6% (n=520) had glaucoma, but only 341 received antiglaucoma drugs. The most frequently prescribed antiglaucoma ophthalmics were beta blockers (n=219), followed by prostaglandin analogues (n=101) and carbonic anhydrase inhibitors (n=86).
The investigators found that local antiglaucoma therapy (ie, drops) was concomitantly prescribed with systemic pharmacotherapy to 338 nursing home residents. In addition, residents receiving an ophthalmic agent were on average receiving 6.5 ± 3.2 prescriptions for systemic agents. When assessing prescribing practices, Huber and colleagues noted several scenarios that increased the risk of potential drug-drug interactions, particularly with regard to cardiac function. These scenarios included prescribing opthalmic beta blockers along with an antihypertensive (71.9%), including a systemic beta blocker (20.2%); prescribing an ophthalmic beta blocker along with cardiac glycosides or calcium antagonists (14%); and coprescribing ophthalmic parasympathomimetics along with cardiac glycosides or calcium antagonists (13%).
Based on the their findings, the authors conclude that the use of ophthalmic drugs in combination with other agents, as often occurs in nursing homes, “may modify the efficacy and safety of local and systemic therapies.” As a result, they note that “individualized pharmacotherapy that integrates anti-glaucoma drug therapy into the overall treatment rationale in nursing home residents is necessary.”