Barriers to vision care for nursing home residents

Objective: To describe the prevalence of periodic eye examinations by eye professionals and to examine nursing facility resident characteristics associated with lack of periodic screening. Design: Retrospective chart review. Setting: Two Midwestern nursing facilities. Participants: Between 1995 and 1997, 134 subjects aged 60 and older were recruited from two metropolitan nursing facilities. Measurements: Nursing home charts were reviewed for: demographics, length of stay, date of eye examination, eye diagnosis, and visual acuity. Nursing assessments were used to obtain information about cognition, function, behavior, and the presence of Do Not Resuscitate or Do Not Hospitalize orders. The chart was reviewed for visual acuity, intraocular pressures, and the presence of eye pathology. Individuals who had not had eye examinations in the previous 2 years were screened by an ophthalmologist. This examination included external examination of the eye, fundoscopic examination, tonometry, and visual acuity with correction. Results: Only 62 (46%) of the subjects had been seen by an eye care professional in the previous 2 years. Visual acuity information was available for 37/64 previously examined subjects. Of those with no eye examination in the previous 2 years (n = 72), visual acuity was obtained in 32 (44%) of subjects. New eye diagnoses were made in 64% (41/64). Logistic regression models with "eye examination within the past 2 years" as the dependent variable show that residents who do not desire hospital transfer are 80% less likely to have had an eye examination than those without this designation. Sex, age, length of stay, functional status, presence of severe dementia, behavior problems, or DNR orders do not change the likelihood that a resident would have been examined. Logistic regression models with "visual acuity measured" as the dependent variable show that residents with severe dementia are 12.6 times less likely to have acuity measured than those without dementia. Those with a length of stay in the facility less than 6 months are 10% less likely to have visual acuity measured. Conclusions: This study does not confirm that barriers still exist in the provision of eye care to all nursing home residents, but the prevalence of such assessments remains low. Additional screening results in a substantial increase in the identification of treatable eye diseases. Contrary to the original hypotheses that patient characteristics that make testing difficult would provide a barrier or disincentive to vision testing, this study did not show statistical differences in the rates of vision screening for those with dementia, behavior problems, or severe functional impairment. Severe dementia does seem to affect the ability of the eye care specialist to gather subjective data such as visual acuity. It also demonstrates that vision screening does take place on nursing home residents with a broad range of cognitive and functional abilities, and this screening results in the diagnosis of many treatable eye conditions. Future efforts should be made to increase vision screening and treatment in the nursing home.