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Original Investigation | Journal Club

Longitudinal Relationships Among Visual Acuity, Daily Functional Status, and Mortality:  The Salisbury Eye Evaluation Study

Sharon L. Christ, PhD1,2; D. Diane Zheng, MS3; Bonnielin K. Swenor, PhD4; Byron L. Lam, MD5; Sheila K. West, PhD4; Stacey L. Tannenbaum, PhD3; Beatriz E. Muñoz, MSc4; David J. Lee, PhD3,5
[+] Author Affiliations
1Department of Human Development and Family Studies, Purdue University, West Lafayette, Indiana
2Department of Statistics, Purdue University, West Lafayette, Indiana
3Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
4Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
5Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
JAMA Ophthalmol. 2014;132(12):1400-1406. doi:10.1001/jamaophthalmol.2014.2847.
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Importance  Determination of the mechanisms by which visual loss increases mortality risk is important for developing interventional strategies.

Objective  To evaluate the direct and indirect effects of loss of visual acuity (VA) on mortality risk through functional status changes among aging adults.

Design, Setting, and Participants  Prospective longitudinal study of a population-based sample of 2520 noninstitutionalized adults aged 65 to 84 years from September 16, 1993, through July 26, 2003, in the greater Salisbury area of Maryland. Participants underwent reassessment 2, 6, and 8 years after baseline. Mortality status was ascertained from linkage with the National Death Index through 2009.

Exposures  Results of VA testing and self-reported functional status based on activities of daily living (ADL) and instrumental ADL (IADL).

Main Outcomes and Measure  Mortality.

Results  Worse VA levels at baseline were associated with an increased the risk for mortality (hazard ratio [HR], 1.16 [95% CI, 1.04-1.28]; P < .01) through their effect on lower IADL levels at baseline. Declines in VA over time were associated with increased mortality risk (HR, 1.78 [95% CI, 1.27-2.51]; P < .001) by way of decreasing IADL levels over time. Participants experiencing the mean linear decline in VA of 1 letter on the Early Treatment Diabetic Retinopathy Study acuity chart per year are expected to have a 16% increase in mortality risk during the 8-year study exclusively through associated declines in IADL levels.

Conclusions and Relevance  In this longitudinal study of older adults, VA loss adversely affected IADL levels, which subsequently increased the risk for mortality. Prevention of disabling ocular conditions, treatment of correctable visual impairment, and interventions designed to prevent the effect of visual impairment on IADL declines may all reduce mortality risk in aging adults.

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Figure.
Final Model of Trajectories of Activities of Daily Living (ADL) and Instrumental ADL (IADL) as Mediators of the Relationship of Visual Acuity (VA) Trajectories, Covariates, and Mortality

Dotted arrows represent pathways that are not statistically significant at α = .05; solid arrows, statistically significant pathways. All pathways control for age, sex, race, educational level, smoking status, alcohol use status, obesity, severe depression, and 15 health conditions (listed in the Measures subsection of the Methods section). Boxes represent variables for which VA at baseline and VA changes over time are independent variables predicting mortality directly and indirectly. The model includes 5 equations (4 for the mediators and 1 for mortality). Parameter estimates from the system of equations were estimated simultaneously. HR indicates hazard ratio.

aP < .01.

bP < .05.

cP < .001.

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