The Value and Underutilization of Simple Reading Glasses in Geropsychiatry Inpatient Settings

Abstract

For almost everyone, the need for reading glasses is an inevitable part of the second half of life. Forgetting one’s reading glasses at a restaurant can be a disturbing reminder of one’s dependence on them. For geriatric inpatients, however, the value of reading glasses in improving quality of life and preventing delirium may be overlooked. Subsequently, the authors present a brief review of visual impairment, the relationship of visual impairment and cognition and the cost of reading glass, and the results of a survey that was conducted to determine the proportion of inpatient geriatric psychiatry inpatient units in the United States, which provide reading glasses to inpatients as well as to assess the knowledge of medical directors of these units regarding the cost and perceived value of providing reading glasses to hospitalized patients.

Visual Impairment and Cognition

Uncorrected visual impairment is surprisingly common among the hospitalized elderly patients, especially among hospitalized patients who are living with dementia. One study showed that more than 30% of inpatients living with dementia had uncorrected refractive errors, usually because the patients had misplaced their glasses or were unable to effectively express a need for vision correction. ¹

The correlation between visual impairment and mental status is well documented. Ong et al ² recently summarized a number of published studies that demonstrated a strong correlation between visual impairment and cognitive decline in the elderly patients. ^{3 -6} Although the etiology of delirium is often complex and elusive, ⁷ McCusker et al ⁸ found that, of the 26 variables studied (age, absent clock, room changes, etc), not wearing prescribed glasses ranked as the fourth most significant factor that precipitated delirium, behind only physical restraints, presence of baseline dementia, and intensive care unit admission. Inouye et al ⁹ found visual impairment to be the most predictive risk factor for delirium, more so than severity of illness, cognitive impairment, and high blood urea nitrogen–creatinine ratio. In addition, others have reported that correction of visual impairment reduces agitation, increases social interaction, and significantly decreases Geriatric Depression Scale scores in a nursing home population. ¹⁰

Although most of the studies mentioned earlier have investigated visual impairment as any type of refractive error, such as myopia (nearsightedness), hyperopia (farsightedness), at least 1 study addressed presbyobia (the condition corrected by reading glasses). Reyes-Ortiz et al ¹¹ found that uncorrected presbyopia among a large sample of elderly Hispanics patients led to significantly lowered Mini-Mental State Examination (MMSE) scores.

Presbyopia

Presbyopia is caused by age-related stiffening of the lens of the eye, resulting in decreased ability to focus light from near objects. The ability of the lens to change shape in order to focus light is known as accommodation. Presbyopia is universal and part of the normal aging process. It progresses in a fairly predictable manner. The average 12-year-old child is able to focus clearly on an object 8 cm from the eye. By age 48, that distance increases to 33 cm as the lens becomes more rigid. By age 60, the lens has essentially lost its ability to contract/expand and the average person has lost accommodation, requiring reading glasses to focus or the ability to stretch one’s arms out any longer. ¹² Reading glasses are not prescription lenses. They come in fixed accommodative powers known as diopters (+1.00 being weaker and +3.00 being stronger) and are available for sale in drug stores or online without an optometrist/ophthalmologist prescription. Because presbyopia progresses in a predictable and an established manner, the strength of one’s reading glasses may be fairly accurately predicted from the chart shown in Table 1. The use of this chart is especially helpful for a patient whose age is known but who may not have the ability to communicate adequately the amount of visual correction needed. ¹⁴

Table 1.

The Predictable Progression of Reading Glass Powers in Adults.^a

Age	Power
45	+1.00
50	+1.50
55	+2.00
60	+2.25
65+	+2.50 to +3.00

^aWhile this table is a standard guide, actual powers may be influenced by underlying refractive error or pathology. Modified from Blystone (1999). ¹³

Cost-Effectiveness

Reading glasses can be purchased in a variety of ways including online. They can be purchased in bulk from Web sites such as www.sharkeyes.com for as little as 90 cents each for various powers. Table 2 puts this cost into perspective along with other common items used in geriatric inpatient care settings. When compared to the cost of providing disposable nonslip socks or disposable adult diapers for geriatric patients, reusable reading glasses are about half the cost of a plastic bed pan and one-tenth that of a patient gown.

Table 2.

Costs of Common Geriatric Supplies With Reading Glasses (bolded).

Item	Cost
Tegaderm Transparent IV Dressinga	US$0.42
Plastic Isolation Gowna	US$0.54
TENA Fresh Underpads (21.5 × 35.4 sq in)b	US$0.60
Adult Nasal Cannulaa	US$0.88
KERLIX Rolla	US$0.88
Dynarex Non Skid Slipper Socksc	US$0.90
Reading glasses d	US$0.90
TENA Classic Briefsb	US$0.99
Slimline Disposable Adult Diapersc	US$1.17
Plastic Bed Pana	US$1.70
Disposable Enema Bag Seta	US$3.19
Foley Catheter Universal Insertion Tray—Sterilea	US$4.07
Cloth Patient Gowna	US$8.67
Aluminum Crutchesa	US$34.25
Front Wheel Walkera	US$61.49

^aPricing source: www.msdepot.com.

^bPricing source: www.parentgiving.com.

^cPricing source: www.mountain-medical.com.

^dPricing source: www.sharkeyes.com.

A Survey of Utility

According to the CEO of the American Association of Geriatric Psychiatry, Chris Devries, a list of all of the geriatric psychiatry inpatient units in the United States does not exist. Given the American College of Graduate Medical Education requirements for geriatric psychiatry fellowship training programs include experience working with geriatric psychiatry inpatients, all institutions with accredited geropsychiatry fellowship programs must provide their fellows with the opportunity to work with older hospitalized psychiatric patients. Many programs fulfill this requirement by having fellows work on geropsychiatry inpatient units. As a result, geropsychiatry training program directors were identified as a conduit to medical directors of geropsychiatry inpatient units. In order to assess the use of reading glasses on inpatient geropsychiatry units, a brief, anonymous, and 3-question survey was sent to the directors of most geropsychiatry fellowship programs around the United States with the hope that the fellowship program directors survey would be willing to forward the survey to the directors of inpatient the geropsychiatry units that support their respective fellowship programs. (Note: the authors learned that several of these programs did not have inpatient geropsychiatry units.)

As shown in Figure 1, despite a relatively accurate knowledge of the low cost of reading glasses as well as a recognition of their helpfulness, 80% of the geropsychiatry units from which completed surveys were returned did not have a stock of reading glasses available to patients. Reading glasses are relatively inexpensive (Table 2). In some locations, it may be possible to purchase glasses with philanthropic donations. For example, the geropsychiatry unit at the University of California, San Diego, received a donation of over 150 reading glasses from the San Diego Depression & Bipolar Support Alliance.

Figure 1.

Results of a 3-question survey sent to directors of inpatient geropsychiatry units across the United States. N = 10.

Conclusion

Reading glasses are an effective and surprisingly inexpensive correction for presbyopia. Uncorrected visual impairment has been shown to decrease quality of life, increase cognitive decline, lower MMSE score, and strongly predispose to delirium. A survey of inpatient geropsychiatry units shows a recognition of the value of reading glasses, yet most units do not have these glasses available. At 90 cents/pair, simple reading glasses should be standard equipment in geriatric psychiatry units.