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. 2015 May 16;55(Suppl 1):S108–S117. doi: 10.1093/geront/gnv028

Vision Impairment Among Older Adults Residing in Subsidized Housing Communities

Amanda F Elliott 1,✉, Gerald McGwin Jr 2,3 , Lanning B Kline 2, Cynthia Owsley 2
PMCID: PMC4566911  PMID: 26055771

Abstract

Purpose of the Study:

To examine the rate of vision impairment and the relationship between vision impairment, cognitive impairment, and chronic comorbid conditions in residents of federally subsidized senior housing facilities.

Design:

Cross-sectional, observational study.

Methods:

Vision screening events were held at 14 subsidized senior housing facilities in Jefferson County, Alabama for residents aged 60 years and older. Visual function (distance vision, near vision, and contrast sensitivity) measured with habitual correction if worn, cognitive status, and chronic comorbid conditions (hypertension, heart problems, circulation problems, and diabetes) were assessed.

Results:

A total of 238 residents participated in the vision screenings. Most residents (75%) were African American. Vision impairment was common, with 40% of participants failing the distance acuity screening and 58% failing the near acuity screening; failure was defined as vision worse than 20/40 in either eye. Additionally, 65% failed the contrast sensitivity screening. A total of 30.6% of seniors had cognitive impairment. Regarding comorbid chronic conditions, 31% had circulation problems, 39% had diabetes, 41% had heart problems, and 76% had hypertension (59% had 2 or more of these). Visual acuity differed significantly between cognitive status groups and with the presence of heart and circulation problems.

Implications:

This study is among the first to provide information about vision impairment in this socioeconomically disadvantaged group of older adults. Vision impairment was common. Cognitive impairment and comorbid chronic conditions accounted for a small to moderate percentage of the variance in distance vision, near vision, and contrast sensitivity. Future studies should focus on strategies to facilitate access to eye care in this vulnerable population.

Key words: Visual function, Socioeconomically disadvantaged, Cognitive status, Chronic disease

Vision Impairment Among Seniors Residing in Subsidized Housing

Vision impairment affects between 2.9 and 3.3 million adults over age 40 in the United States (Congdon et al., 2004; Prevent Blindness, 2012). One out of six Americans aged 70 years and older has measured vision impairment, and more than 60,000 Alabamians aged 60 years and older have low vision or blindness (Dillon, Gu, Hoffman, & Ko, 2010; Prevent Blindness, 2012). Disparities in rates of measured vision impairment are well documented and have existed for decades (Klein, Klein, Jensen, Moss, & Cruickshanks, 1994; National Eye Institute, 2010; Tielsch, Sommer, Katz, Quigley, & Ezrine, 1991; West et al., 1997). Specifically, rates of measured vision impairment are significantly greater among older adults, those disadvantaged socioeconomically, and African Americans (Baker, Bazargan, Bazargan-Hejazi, & Calderón, 2005; Dillon et al., 2010; Tielsch et al., 1991; Zheng et al., 2011). These same groups of people are also more likely to experience higher rates of chronic comorbid conditions such as hypertension and diabetes which can lead to eye disease and vision loss (Kaplan, Huguet, Feeny, & McFarland, 2010; Ko et al., 2012; Zambelli-Weiner, Crews, & Friedman, 2012; Zhang et al., 2012). Wong and Mitchell (2007) illustrate that the profound visual changes and complications (such as retinal vein and artery occlusion) associated with hypertension may lead to significant visual impairment and potential blindness. They also suggest that hypertension could be a pathogenic factor for glaucoma and age-related macular degeneration. Additionally, findings from the National Health Interview Survey show that older adults with vision impairment are more likely than those without vision impairment to have hypertension and diabetes (Crews & Chou, 2012).

The presence of chronic conditions and vision impairment are both independently related to decreased health-related quality of life in older adults (Barile et al., 2012; Li et al., 2011). Additionally, Hu (2007) found that health-related quality of life was lower among older African Americans living in subsidized senior housing when compared to the U.S. general population norms for people aged 60 years and older. Furthermore, research has shown that measured vision impairment is related to the incidence of cognitive impairment (Lin et al., 2004; Ong et al., 2012; Reyes-Ortiz et al., 2005) and the progression of cognitive impairment is among the key factors related to progression to institutionalization (Gnjidic et al., 2012; Phillips et al., 2003). Since the likelihood of having chronic medical conditions and vision impairment is higher in older, African Americans with low incomes as compared to younger people with higher incomes, it is imperative to focus public health services such as screening programs and preventive measures in this population.

African Americans are overrepresented in public housing programs, making up 45% of residents across all types of public housing programs (National Low Income Housing Coalition, 2012). The 2011 National Health and Aging Trends study found that among Medicare beneficiaries aged 65 years and older, 2.5 million lived in retirement or senior housing communities where 37% of these residents were found have unmet needs related to difficulty with household, self-care, or mobility (Freedman & Spillman, 2014). Therefore, the present study aimed to recruit older African American adults living in federally subsidized senior housing communities for participation in vision screening events. These facilities rent safe and clean apartments to seniors who do not own their own homes and who are unable to afford the rental rates of regular housing in their communities. These facilities fulfill a special niche for seniors, most of whom have worked all their adult lives yet who, during the course of their adulthood, were unable to accumulate financial resources to purchase their own homes, or who were forced to sell their homes in order to make ends meet. Eligibility for living in rent-subsidized senior facilities is reserved for those on very limited annual incomes. The purpose of this study was to elucidate the rate of vision impairment in older adults residing in subsidized senior housing complexes serving predominantly African American communities and to identify the relationship between vision impairment and comorbid chronic conditions and cognitive impairment.

Design and Methods

Participants

Inclusion criteria consisted of adults (≥60 years) who could speak and understand English and who resided in federally subsidized senior housing communities in Jefferson County, Alabama (the Birmingham, Alabama metropolitan area). Federally subsidized senior housing communities were identified through the Department of Housing and Urban Development. The manager at each community was sent a recruitment letter inviting the community to participate in a no-cost vision screening event to be held at their housing community. Each housing community received at least two follow-up telephone calls from the project manager to determine whether they were interested in having an event at their facility. After two unreturned follow-up phone calls and voice messages, it was concluded that the housing community was uninterested. Of the 19 federally subsidized senior housing communities identified in Jefferson County, Alabama, 14 desired to participate, one declined participation, and four were unreachable via letter and telephone (74% participation rate). For those community managers who agreed to have a screening event, the project manager met with them and worked out the details on the screening date and location within the community.

Procedures

Two weeks prior to the date of the vision screening, packets were mailed to each housing community’s manager containing letters to be distributed to all of the residents. Letters described the vision screening event including the date, time, and location where it would be held onsite. Fliers containing this same information were also provided to the community manager to be posted around the community in advance of the screening event. On the day of the screening event, residents were seen on a first come, first served basis although some residents had chosen to make appointments in advance as this option was offered through the letters/fliers they received in advance of the screenings. If all interested residents at a community could not be accommodated in a single day, arrangements were made to return to provide additional screening events. No person was denied vision screening.

Measures

The study had a cross-sectional design. Informed consent was obtained from each participant prior to administration of all protocol measurements by trained research staff. This study was approved by the Institutional Review Board of the University of Alabama at Birmingham and followed the tenets of the Declaration of Helsinki.

Three screening tests of vision function were conducted. Each of the following tests was administered as described previously for another older adult population (Elliott, McGwin, & Owsley, 2013). Each eye was assessed separately with the participant viewing with whatever habitual correction they would normally use (if they used any) for each vision test. Distance letter visual acuity was measured by the ETDRS charts and accompanying light box (Ferris, Kassoff, Bresnick, & Bailey, 1982). Letter visual acuity for near vision was assessed by the Lighthouse Near Visual Acuity card (Owsley et al., 2007a). The Mars Letter Contrast Sensitivity Test was used to assess contrast sensitivity (Arditi, 2005). Participants were then asked to complete interviewer-administered questionnaires on basic demographic information (e.g., birth date, sex, race/ethnicity, marital status, and education level) and the presence of diagnosed chronic comorbid medical conditions (circulation problems, diabetes, heart problems, and hypertension). General mental status was assessed by the Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975). Each participant was asked to read and sign a medical release form that gave the study permission to obtain their most recent eye examination record from their ophthalmologist or optometrist. After the eye record was obtained, diagnosed eye conditions were abstracted and recorded.

The definitions used for vision impairment (i.e., “screen failure”) for the three vision screening tests (distance acuity, near acuity, contrast sensitivity) are identical to those used in our earlier work (Elliott et al., 2013). A screen failure for both the distance and near visual tests was defined as acuity worse than 20/40 in at least one eye. A screen failure for contrast sensitivity was defined as a score worse than 1.50 in at least one eye. All participants were provided with a report describing their vision screening results. If a participant failed any of the vision screening tests, they were given a letter encouraging them to seek a comprehensive eye exam by their eye care provider (ophthalmologist or optometrist) if they were not already receiving routine care. If they preferred, we sent this report directly to their eye care provider. In the event that the participant did not have an established relationship with an eye care provider, we provided information on eye care providers in their community and offered assistance in making an appointment.

Statistical Analysis

The visual functional status of the sample was calculated through use of descriptive statistics (e.g., means, proportions). The definition for vision impairment for each of the three tests of vision (distance, near, and contrast sensitivity) is described above. Chi-square tests were used to test for significant differences between those with and without cognitive impairment. Multiple linear regression was used to evaluate the association between chronic comorbid medical conditions and visual status with and without adjustment for MMSE score.

Results

A total of 267 people attended the vision screening events at the subsidized senior housing communities. Of these, 28 were deemed ineligible to complete the study measures (26 due to age < 60 years, 2 due to not being residents at the community). One additional person declined to complete the vision screening tests, leaving a total analysis sample of 238 participants. This represents a total response rate of approximately 25% of the total number of residents at all of the communities. This ranged from as low as 9% to as high as nearly 40% across individual communities. Demographic characteristics of the participants are listed in Table 1. Approximately 70% were less than 80 years of age, 74% were female, and 75% were African American, non-Hispanic. About 40% of participants had not completed high school and nearly all participants (98%) were single (including separated, divorced, and widowed) and lived alone. Forty percent of participants had cataracts as confirmed by medical record diagnosis. Regarding participants’ comorbid chronic conditions, 31% had circulation problems, 39% had diabetes, 41% had heart problems, and 76% had hypertension (59% had two or more of these). Additionally, almost one-third (30.6%) of participants were considered cognitively impaired according to their MMSE score (i.e., a score ≤ 23).

Table 1.

Demographic and Medical Characteristics of Subsidized Senior Housing Participants

Characteristic No. (%)
Age, years
 60–69 79 (33.12)
 70–79 89 (37.39)
 80–89 51 (21.43)
 90+ 19 (7.98)
Sex
 Male 62 (26.05)
 Female 176 (73.95)
Race/ethnicity
 White, non-Hispanic 57 (23.95)
 African American, non-Hispanic 178 (74.79)
 Other (native American, Indian, Brazilian) 3 (1.26)
Education
 <12 98 (41.53)
 High school graduate 79 (33.47)
 Some college 46 (19.49)
 College graduate 10 (4.24)
 Graduate or professional degree 3 (1.27)
Marital status
 Married 5 (2.11)
 Single 62 (26.16)
 Separated 9 (3.80)
 Divorced 56 (23.63)
 Widowed 105 (44.30)
Social support
 Live alone 234 (98.32)
 Live with a family member/friend 4 (1.68)
Medical conditions
 Heart problem 99 (41.77)
 Circulation problems 76 (31.93)
 Hypertension 180 (75.63)
 Diabetes 93 (39.08)
MMSE scorea
 27–30 103 (43.27)
 24–26 62 (26.05)
 20–23 42 (17.64)
 16–19 19 (7.98)
 13–15 5 (2.10)
 10–12 4 (1.68)
 <10 3 (1.26)
Eye diseases
 Cataract 96 (40.51)
 Diabetic retinopathy 14 (5.91)
 Glaucoma 32 (13.50)
 Age-related macular degeneration 10 (4.22)
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Notes: MMSE = Mini-Mental State Examination.

aMMSE, normal range 24–30, ≤23 indicates cognitive impairment.

Visual function as assessed by distance and near acuity and contrast sensitivity testing is summarized in Table 2. With regard to vision in the better seeing eye (defined as whichever eye had higher distance or near visual acuity scores and higher contrast sensitivity scores), 81.5% of participants had 20/40 or better acuity for distance vision, 65.6% had 20/40 or better acuity for near vision, and 63.3% had greater than or equal to 1.50 contrast sensitivity. With regard to the worse seeing eye, the rates were lower such that only 57.7% of participants had 20/40 or better acuity for distance vision, 41% of participants had 20/40 or better acuity for near vision, and 34.7% had greater than or equal to 1.50 contrast sensitivity. Chi-square analyses were conducted to detect differences in visual acuity by gender and race (results not shown). There were no significant differences between genders or racial categories in visual acuity in this sample.

Table 2.

Visual Function Characteristics of Subsidized Senior Housing Participants

Characteristic Better eye Worse eye
Distance visual acuity, no. (%)
 20/40 or better 180 (81.45) 128 (57.66)
 Worse than 20/40  but better than 20/200 38 (17.19) 76 (34.23)
 20/200 or worse 3 (1.36) 18 (8.11)
Distance visual acuity, logMARa, mean (SD) 0.16 (0.23) 0.40 (0.41)
Near visual acuity, no. (%)
 20/40 or better 149 (65.64) 93 (40.97)
 Worse than 20/40  but better than 20/200 76 (33.48) 117 (51.54)
 20/200 or worse 2 (0.88) 17 (7.49)
Near visual acuity, logMAR, mean (SD) 0.25 (0.21) 0.45 (0.33)
Contrast sensitivity, no. (%) b b
 ≥1.80 126 (63.32) 69 (34.67)
 ≥1.50 but <1.80 62 (31.16) 87 (43.72)
 ≥1.20 but <1.50 b 21 (10.55)
 ≥0.90 but <1.20 8 (4.02) 4 (2.01)
 ≥0.60 but <0.90 1 (0.50) 3 (1.51)
 ≥0.30 but <0.60 2 (1.01) 15 (7.54)
 <0.30
Contrast sensitivity, log sensitivity, mean (SD) 1.52 (0.28) 1.28 (0.43)
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Notes: aLogMAR is the logarithm of the minimum angle of resolution; it represents a measure of the actual number of letters read on the vision charts.

b N = 0.

The results of the vision screening are presented in Table 3 in a pass-versus-fail manner. Forty percent of participants failed the distance visual acuity test, meaning that at least one eye had a distance visual acuity of worse than 20/40. For the near visual acuity test, the percentage of people who failed rose to 58%, and for contrast sensitivity, the rate of failure was even higher at 65%.

Table 3.

Visual Acuity Screening Results for Distance and Near Vision and Contrast Sensitivity

Vision measure Number (% of total)
Distance visual acuity
 Passed screening test 142 (59.92)
 Failed screening test 95 (40.08)
Near visual acuity
 Passed screening test 99 (41.95)
 Failed screening test 137 (58.05)
Contrast sensitivity
 Passed screening test 69 (34.67)
 Failed screening test 130 (65.33)
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Visual acuity for distance and near vision (as measured with the continuous variable logMAR) and contrast sensitivity for participants by cognitive status group and chronic comorbid medical conditions are presented in Tables 4 and 5. People with self-reported heart problems and circulation problems tended to have worse visual acuity (distance and near) and worse contrast sensitivity than those with self-reported hypertension and diabetes. Heart problems were significantly associated with distance visual acuity in the better and worse eye, circulation problems were additionally associated with distance visual acuity in the worse eye; a similar pattern was observed for near visual acuity (Table 6). None of the other comorbidities were significantly associated with either distance or near visual acuity. For contrast sensitivity, the only significant association was for heart problems though only in the worse eye. When additionally adjusted for MMSE score, the aforementioned pattern of results persisted and MMSE score was significant in all models (Table 6).

Table 4.

Vision Screening Results for Distance and Near Vision and Contrast Sensitivity by MMSE Score

Characteristic MMSEa
>23 (N = 165) ≤23 (N = 73)
Better eye Worse eye Better eye Worse eye
Distance visual acuity, no. (%)
 20/40 or better 138 (87.90) 106 (67.52) 42 (65.63) 22 (33.85)
 Worse than 20/40 but better than 20/200 17 (10.83) 41 (26.11) 21 (32.81) 35 (53.85)
 20/200 or worse 2 (1.27) 10 (6.37) 1 (1.56) 8 (12.31)
Distance visual acuity, logMARb, mean (SD) 0.13 (0.22) 0.34 (0.40) 0.25 (0.25) 0.54 (0.41)
Near visual acuity, no. (%) 112 (70.44) 78 (49.06) 37 (54.41) 15 (22.06)
 20/40 or better 47 (29.56) 71 (44.65) 29 (42.65) 46 (67.75)
 Worse than 20/40 but better than 20/200 — 10 (6.29) 2 (2.94) 7 (10.29)
 20/200 or worse
Near visual acuity, logMAR, mean (SD) 0.22 (0.18) 0.41 (0.32) 0.33 (0.24) 0.55 (0.35)
Contrast sensitivity, no. (%) — — — —
 ≥1.80 100 (71.94) 58 (41.73) 26 (43.33) 11 (18.33)
 ≥1.50 but <1.80 32 (23.02) 58 (41.73) 30 (50.00) 29 (48.33)
 ≥1.20 but <1.50 5 (3.60) 10 (7.19) 3 (5.00) 11 (18.33)
 ≥0.90 but <1.20 — 1 (0.72) — 3 (5.00)
 ≥0.60 but <0.90 1 (0.72) 2 (1.44) — 1 (1.67)
 ≥0.30 but <0.60 1 (0.72) 10 (7.19) 1 (1.67) 5 (8.33)
 <0.30
Contrast sensitivity, log sensitivity, mean (SD) 1.55 (0.21) 1.33 (0.42) 1.43 (0.25) 1.17 (0.43)
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Notes: MMSE = Mini-Mental State Examination.

aMMSE, normal range 24–30, ≤23 indicates cognitive impairment.

bLogMAR is the logarithm of the minimum angle of resolution; it represents a measure of the actual number of letters read on the vision charts.

Table 5.

Vision Screening Results for Distance and Near Vision and Contrast Sensitivity by Chronic Comorbid Medical Conditions

Characteristic Chronic comorbid conditions
Heart problems (N = 99) Circulation problems (N = 76) Hypertension (N = 180) Diabetes (N = 93)
Better eye Worse eye Better eye Worse eye Better eye Worse eye Better eye Worse eye
Distance visual acuity, no. (%) 66 (75.00) 40 (45.45) 55 (78.57) 37 (52.80) 138 (81.66) 97 (57.06) 73 (83.91) 49 (56.32)
 20/40 or better 20 (22.73) 35 (39.77) 13 (18.57) 22 (31.43) 29 (17.16) 60 (35.29) 14 (16.09) 33 (37.93)
 Worse than 20/40  but better than 20/200 2 (2.27) 13 (14.77) 2 (2.86) 11 (15.71) 2 (1.18) 13 (7.65) — 5 (5.75)
 20/200 or worse
Distance visual acuity, logMARa, mean (SD) 0.21 (0.27) 0.53 (0.50) 0.18 (0.28) 0.53 (0.51) 0.16 (0.22) 0.39 (0.40) 0.14 (0.16) 0.36 (0.33)
Near visual acuity, no. (%)
 20/40 or better 57 (59.38) 34 (35.42) 40 (54.79) 27 (36.99) 113 (65.70) 70 (40.70) 60 (65.93) 38 (41.76)
 Worse than 20/40 but better than 20/200 37 (38.54) 47 (48.96) 31 (42.47) 33 (45.21) 59 (34.30) 91 (52.91) 31 (34.07) 49 (53.85)
 20/200 or worse 2 (2.08) 15 (15.63) 2 (2.74) 13 (17.81) — 11 (6.40) — 4 (4.40)
Near visual acuity, logMAR, mean (SD) 0.30 (0.24) 0.55 (0.41) 0.30 (0.27) 0.56 (0.43) 0.25 (0.19) 0.45 (0.32) 0.24 (0.17) 0.44 (0.30)
Contrast sensitivity, no. (%) — — — — — — — —
 ≥1.80 51 (58.62) 22 (25.29) 41 (60.29) 19 (27.94) 96 (62.75) 48 (31.37) 48 (62.34) 22 (28.57)
 ≥1.50 but <1.80 28 (32.18) 36 (41.38) 21 (30.88) 26 (38.24) 49 (32.03) 71 (46.41) 26 (33.77) 38 (49.35)
 ≥1.20 but <1.50 6 (6.90) 13 (14.94) 4 (5.88) 9 (13.24) 6 (3.92) 18 (11.76) 3 (3.90) 10 (12.99)
 ≥0.90 but <1.20 — 2 (2.30) — 2 (9.4) — 3 (1.96) — 2 (2.60)
 ≥0.60 but <0.90 1 (1.15) 2 (2.30) 1 (1.47) 3 (4.41) 1 (0.65) 3 (1.96) — —
 ≥0.30 but <0.60 1 (1.15) 12 (13.79) 1 (1.47) 9 (13.24) 1 (0.65) 10 (6.54) — 5 (6.49)
 <0.30
Contrast sensitivity, log sensitivity, mean (SD) 1.48 (0.25) 1.14 (0.52) 1.49 (0.28) 1.15 (0.53) 1.52 (0.21) 1.28 (0.41) 1.53 (0.15) 1.27 (0.39)
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Note: aLogMAR is the logarithm of the minimum angle of resolution; it represents a measure of the actual number of letters read on the vision charts.

Table 6.

Summary of Multiple Regression Analyses for Chronic Comorbid Medical Conditions, With and Without MMSE, Predicting Visual Acuity, and Contrast Sensitivity

Predictor variable Distance VA Near VA Contrast sensitivity
Better eye Worse eye Better eye Worse eye Better eye Worse eye
β p β p β p β p β p β p
Model 1
 Heart problems −.081 .019 −.205 .001 −.064 .032 −.142 .003 .052 .152 .200 .003
 Circulation problems −.004 .922 −.127 .040 −.055 .079 −.113 .022 .031 .407 .132 .052
 Hypertension .025 .506 .051 .434 .025 .442 .042 .414 −.005 .891 −.046 .517
 Diabetes .056 .091 .105 .061 .043 .133 .059 .191 −.034 .325 −.050 .424
 R 2 .038 .107 .056 .093 .023 .096
 F (df) 2.17 (4, 215) 6.44 (4, 216) 3.29 (4, 221) 5.63 (4, 221) 1.15 (4, 193) 5.14 (4, 193)
Model 2
 Heart problems −.074 .027 −.194 .001 −.056 .051 −.131 .005 .047 .168 .194 .003
 Circulation problems −.004 .905 −.129 .029 −.052 .085 −.108 .024 .029 .407 .130 .051
 Hypertension .009 .804 .027 .667 .014 .658 .028 .575 .014 .699 −.022 .754
 Diabetes .052 .095 .098 .069 .036 .185 .051 .248 −.029 .362 −.044 .464
 MMSEa score −.015 .000 −.024 .000 −.013 .000 −.016 .000 .017 .000 .021 .001
 R 2 .126 .183 .140 .142 .145 .149
 F (df) 6.16 (5, 214) 9.62 (5, 215) 7.17 (5, 220) 7.29 (5, 220) 6.51 (5, 192) 6.70 (5, 192)
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Notes: Self-reported chronic diseases were coded as 1 = Yes, 2 = No. MMSE = Mini-Mental State Examination; VA = Visual Acuity.

aMMSE, normal range 24–30, ≤23 indicates cognitive impairment.

Discussion

For older adults living in federally subsidized senior housing communities, the ability to maintain one’s health and manage day to day activities is essential to remain living independently, as no formal assistance is provided to these older adults as part of living in these communities. Previous research has suggested that both increased age and lower socioeconomic status are associated with vision impairment (Zheng et al., 2011). Therefore, we aimed to assess rates of visual impairment in a group of older, socioeconomically disadvantaged adults in our community. Since nearly three-quarters of the federally subsidized senior communities within predominately African American communities in our area were interested in hosting our vision screening event, we found this to be an accessible population to reach with vision health surveillance efforts. Further, since we identified a substantial amount of vision impairment worse than 20/40, this population also represents a segment of the population who are in disproportionate need of visual health surveillance efforts. This is comparable to what was previously found by Winters and Pihos (2008) among a similar population of seniors in low-income housing in Chicago.

Our study is among the first to examine visual impairment using objective measures (distance acuity, near acuity, and contrast sensitivity) in this population. Previous work with low-income older adults has primarily focused on determining rates of eye care utilization, not providing vision screening results (Malmgren, Martin, & Nicola, 1996). Previous studies that have reported visual function data have used participants’ self-report of visual ability (Baker et al., 2005; Chou et al., 2012; Jin, Buys, Xiong, & Trope, 2013). We found only one previous study that specifically provided senior residents of low-income housing facilities with objective eye examinations. In this study by Winters and Pihos (2008), participants were transported to the local university eye clinic for dilated eye examination by an optometrist; vision screenings were not provided on site at the residential community. The authors state that not having on site screenings may have affected the buy-in from residents as their total sample was low. A strength of our study was that all screenings were done on site at each residential community in rooms they were familiar with and could easily access without having to leave their place of residence. This may have led to our ability to enroll a large number of participants since it showed that the community managers were aware of and supported our vision screening events.

Although our study was demographically similar to that of Winters and Pihos (2008), we had higher rates of vision impairment in our sample (41% compared to 26%). This is likely due to differences in defining vision impairment between studies. In the present study, vision impairment was defined as presenting distance visual acuity (with habitual correction if worn) worse than 20/40 in either eye in order to understand the scope of visual impairment in this population while the previous study defined visual impairment as presenting visual acuity worse than 20/40 in the better seeing eye. If we were to define visual impairment as worse than 20/40 in the better seeing eye for distance or near and/or less than 1.50 for contrast sensitivity, we find vision impairment in distance vision for 18.6% of residents, in near vision for 34.4% of residents, and in contrast sensitivity for 41.7% of residents. Our finding that 18.6% of our population was visually impaired based on the commonly accepted definition of visual impairment is still much higher than population estimates for adults aged 60 years and older which are 8.8% (Vitale, Cotch, & Sperduto, 2006). A distinctive difference between our study and previous population-based studies on vision impairment in the United States is that our sample focused on socioeconomically disadvantaged older adults whereas the population estimates were created for a normative U.S. sample. Although our sample represents an underserved population in terms of vision health services, it illustrates the elevated rate of vision impairment among older adults who are socioeconomically disadvantaged.

The present study also found that chronic comorbid conditions and cognitive status contributed significantly to the prediction of visual impairment in this population. Interestingly, self-reported heart problems and circulation problems were predictive of vision impairment and self-reported hypertension and diabetes were not. Typically, hypertension and diabetes are the two chronic comorbid conditions that are assessed in vision research as they represent disease processes with direct implications for vision. Our findings that self-reported heart problems and circulation problems were superior to self-reported hypertension and diabetes in predicting visual impairment suggest that when asking older adults to self-report their medical history, these two conditions should also be included. From a healthcare perspective, these finding support the current recommendations that older adults with these chronic diseases should obtain annual eye examinations. Additionally, management of hypertension in primary care in conjunction with consistent vision screenings could greatly reduce vision-related complications in this population.

It has been estimated that 60% of visual impairment in adults aged 60 years and older in the United States was due to uncorrected refractive error (Vitale et al., 2006). Since our sample had high rates of near vision impairment, a prominent candidate mechanism underlying their near vision impairment is presbyopia, which is also highly correctable. Based on medical record data, 40% of our sample had diagnosed cataracts that also may have contributed to impaired vision. We suspected that the presence of cataract may have influenced contrast sensitivity scores especially. However, we found that contrast sensitivity scores did not differ significantly in either the better or worse eye between those with and without cataracts (results not shown). Several studies have clearly documented that impaired visual acuity in older adults, specifically for near distances, increases the risk for incident or the worsening of cognitive impairment or performance (Lin et al., 2004; Reyes-Ortiz et al., 2005). Cognitive impairment is a major factor leading to institutionalization (Luppa, Luck, Weyerer, König, & Riedel-Heller, 2010) and both vision impairment and cognitive impairment are related to decreased quality of life among older adults (Elliott, McGwin, & Owsley, 2009). Additionally, impaired cognition and vision have a strong relationship with a deleterious impact on older adults’ performance of many everyday activities such as reading, mobility, and social interaction (Coleman, Yu, Keeler, & Mangione, 2006; Valbuena, Bandeen-Roche, Rubin, Munoz, & West, 1999). Previous research has demonstrated that improving vision through the correction of refractive error and cataract surgery in older adults can improve quality of life (Coleman et al., 2006; Fraser, Meuleners, Lee, Ng, & Morlet, 2013; Owsley et al., 2007b). Our sample had a high rate of near visual impairment and impaired contrast sensitivity scores. In addition, since cognitive status did contribute to the prediction of visual impairment, we should consider that interventions to improve vision may also aid in reducing incident cognitive impairment, a major predictor of transition to nursing home placement (Phillips et al., 2003). This is a hypothesis that deserves further evaluation.

A strength of this study is that it is among the first to look at vision impairment rates in older adults residing in federally subsidized housing communities. Valid and reliable objective tools for measuring visual acuity and contrast sensitivity were employed. A limitation is that we used self-reported data for medical conditions which is potentially at risk for participant recall bias and thus should be interpreted with caution. While we obtained medical records related to participants’ visits to eye care providers, we did not obtain comprehensive medical records for participants in this study. Previous research has supported the use of self-report for presence of chronic diseases, especially for diabetes, however older adults do tend err on the side of underreporting their chronic diseases (Goldman, Lin, Weinstein, & Lin, 2003; Leikauf & Federman, 2009; Wu, Li, & Ke, 2000). Overall participation rates, based on the approximate total number of residents at each facility, was nearly 25%; this number may in actuality be higher if we were to limit this to only residents who would have been qualified for our study by being 60 years of age or older. Twenty-eight people (10%) who came to the screenings were younger than 60; unfortunately, we do not know the proportion of people between 55 and 60 years of age living at each community. Even though we had high turnout at our vision screening events as verified by staff at each community, it is possible that those who chose to come to the events were more concerned about their vision than residents who did not attend the event. Yet acknowledging this potential for participation bias, our vision screening program did reveal a subpopulation of residents who had high rates of visual impairment. This may limit the generalizability of these findings to other similar residential settings. An important outcome of evaluating vision screening programs among those “positive” for vision impairment is determining who actively seeks dilated comprehensive eye care and what then are the eventual outcomes of this medical intervention. Further analyses related to eye care utilization in this sample will be discussed elsewhere. The American Academy of Ophthalmology (2009) recommends that adults 65 years of age and older have an eye examination every 1–2 years, even in the absence of symptoms. In addition to future research determining what proportion seek follow-up eye care after a screening, future work should strive to achieve a better understanding about the factors that impact eye care utilization among older adults including those residing in subsidized senior housing communities. It would also be an important contribution to provide full eye exams on site in senior housing communities. Additionally, in order to maintain the independence of this population, management of chronic conditions such as hypertension and prevention of or treatment for vision impairment will be essential. Additional future areas that would be important to consider would be the rate of depression and hearing loss in this population. The present study did not measure depression or hearing; however, previous research has found that there is a direct relationship between depression and visual impairment, with rates ranging from 7% to 39% so it would be important to consider this as an influencing factor (Renaud & Bédard, 2013). Hearing loss has been found to be independently associated with incident dementia (Lin et al., 2011) and dual sensory impairment (vision and hearing) could potentially accelerate cognitive decline. Incorporating the use of cognitive function instrumentation that is sensitive to visual and hearing impairments will be an important contribution to determining the actual effect of the impairment on cognition, not just a potential measurement error resulting from needing nonimpaired senses to complete the cognitive test. Overall, the results of the present study underscore the importance of providing vision health surveillance efforts to older adults, especially those who are members of high at risk groups so that we can identify those in need of eye care and begin to address issues surrounding access to care in this population.

Funding

This work was supported by The Lucille Beeson Trust; Prevent Blindness; the EyeSight Foundation of Alabama; the Able Trust; the Alfreda J. Schuler Trust; National Institutes of Health (grant P30-AG22838); and Research to Prevent Blindness Inc.

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