Original Investigation | Socioeconomics and Health Services

A Low-Vision Rehabilitation Program for Patients With Mild Cognitive Deficits

Heather E. Whitson, MD, MHS1,2,5; Diane Whitaker, OD2,6; Guy Potter, PhD3; Eleanor McConnell, RN, PhD7; Fay Tripp, OT4; Linda L. Sanders, MPH1; Kelly W. Muir, MD, MHS2,5,6; Harvey J. Cohen, MD1; Scott W. Cousins, MD2,6
[+] Author Affiliations
1Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
2Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
3Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
4Department of Physical Therapy and Occupational Therapy, Duke University Medical Center, Durham, North Carolina
5Durham Veterans Affairs Medical Center, Durham, North Carolina
6Duke Eye Center, Durham, North Carolina
7School of Nursing, Duke University, Durham, North Carolina
JAMA Ophthalmol. 2013;131(7):912-919. doi:10.1001/jamaophthalmol.2013.1700.
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Importance  We are unaware of any standardized protocols within low-vision rehabilitation (LVR) to address cognitive impairment.

Objective  To design and pilot-test an LVR program for patients with macular disease and cognitive deficits.

Design  The Memory or Reasoning Enhanced Low Vision Rehabilitation (MORE-LVR) program was created by a team representing optometry, occupational therapy, ophthalmology, neuropsychology, and geriatrics. This pilot study compares outcomes before and after participation in the MORE-LVR program.

Setting  Eligible patients were recruited from an LVR clinic from October 1, 2010, through March 31, 2011.

Participants  Twelve patients completed the intervention, and 11 companions attended at least 1 training session.

Intervention  Key components of the MORE-LVR intervention are as follows: (1) repetitive training with a therapist twice weekly during a 6-week period, (2) simplified training experience addressing no more than 3 individualized goals in a minimally distracting environment, and (3) involvement of an informal companion (friend or family member).

Main Outcome Measures  Version 2000 National Eye Institute Vision Function Questionnaire–25; timed performance measures, Telephone Interview for Cognitive Status-modified(TICS-m), Logical Memory tests, satisfaction with activities of daily living, and goal attainment scales.

Results  Twelve patients without dementia (mean age, 84.5 years; 75% female) who screened positive for cognitive deficits completed the MORE-LVR program. Participants demonstrated improved mean (SD) scores on the National Eye Institute’s Visual Function Questionnaire–25 composite score (47.2 [16.3] to 54.8 [13.8], P = .01) and near-activities score (21.5 [14.0] to 41.0 [23.1], P = .02), timed performance measures (writing a grocery list [P = .03], filling in a crossword puzzle answer [P = .003]), a score indicating satisfaction with independence (P = .05), and logical memory (P = .02). All patients and companions reported progress toward at least 1 individualized goal; more than 70% reported progress toward all 3 goals.

Conclusions and Relevance  This pilot study demonstrates feasibility of an LVR program for patients with macular disease and mild cognitive deficits. Participants demonstrated improvements in vision-related function and cognitive measures and expressed high satisfaction. Future work is needed to determine whether MORE-LVR is superior to usual outpatient LVR for persons with coexisting visual and cognitive impairments.

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Figure 1.
Cognitive Deficit Screening Form Items From the Cognitive Screen Are Adapted From the Wechsler Memory Scale III–Revised Word List A and the /F/A/S/ Verbal Fluency Test

The screen was designed to be brief and easy to administer and score. Poor word recall has been linked to worse functional trajectories among low-vision rehabilitation patients,30 and older adults with macular disease have been shown to exhibit low scores on tests of verbal fluency.28 The screen is positive if the patient performs below the cut point for word recall or verbal fluency.

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Figure 2.
Study Flow Diagram For The 31 Patients With Macular Disease Who Were Older Than 65 Years And Presented For Evaluation at the Duke Low Vision Clinic, Where They Screened Positive For Cognitive Deficits

Of these patients, 6 were excluded and 11 declined to participate. Most patients who declined to participate lived more than 30 miles from the study center (and thus were not eligible for in-home training) and could not commit to twice-weekly visits. Two patients indicated that their medical health was too tenuous to participate in the rehabilitation program, whereas another patient was not able to participate because of her duties as a caregiver. Fourteen patients enrolled in the study, and 12 completed the Memory or Reasoning Enhanced Low Vision Rehabilitation intervention. CCTV indicates closed circuit television.

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Figure 3.
Examples of Performance Measures Before and After the Memory or Reasoning Enhanced Low Vision Rehabilitation (MORE-LVR) Intervention

These examples, taken from 2 different participants, demonstrate postintervention improvement on 2 near-vision tasks: filling in a crossword puzzle and writing a grocery list. Instructions were read out loud to patients, who were allowed to use a closed circuit television (CCTV) or other vision assistive equipment to complete each task. After participation in MORE-LVR, the patients completed the tasks more quickly, and the result is more legible. The second patient had a tremor in addition to low vision; her writing improved after receiving training from the occupational therapist relevant to both the tremor and central vision loss. A strength of the MORE-LVR program is that it provides sufficient one-on-one attention from an occupational therapist to address the complex interactions of multiple comorbidities on patients’ ability to achieve their vision-related goals.

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