|Year : 2020 | Volume
| Issue : 1 | Page : 30-37
Vision-Related Quality of Life Assessment of Patients Attending a Geriatric Centre in South-West Nigeria
O. I. Majekodunmi, O. A. Ogun, O. O. Ayorinde
Department of Ophthalmology, University College Hospital, Ibadan, Nigeria
|Date of Submission||30-Mar-2019|
|Date of Decision||26-May-2020|
|Date of Acceptance||02-Jun-2020|
|Date of Web Publication||07-Sep-2020|
Dr. O. I. Majekodunmi
Department of Ophthalmology, University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Majekodunmi OI, Ogun OA, Ayorinde OO. Vision-Related Quality of Life Assessment of Patients Attending a Geriatric Centre in South-West Nigeria. Niger J Ophthalmol 2020;28:30-7
| Background|| |
According to World Health Organization, health not only refers to the absence of physical diseases, but also includes psychological and social well-being of individuals. Quality of life (QoL) on the other hand, lacks a single, universally accepted definition. However, QoL may be defined subjectively as “an individual’s perception of his/her life in the context of the culture and value system in which they live, and in relation to their goals, expectations, standards and concerns. QoL also has an objective component which can be measured objectively using validated instruments (e.g. questionnaires) in which a score is assigned to specific indices or characteristics in different domains along a scale in a continuum.,,
Visual function is important for optimal orientation in functional and social life and has effects on physical, psychological, mental and emotional well-being of the individual. Visual function therefore is a domain under which QoL may be assessed. This is referred to as vision-specific or vision-related QoL. The National Eye Institute Visual Function Questionnaire (NEI-VFQ) is an example of an instrument designed and validated for the objective assessment of vision-specific QoL.
Broman et al. revealed that a visual acuity of at least 6/12 was found to negatively impact on an individual’s quality of life. This was also reiterated by Bekibele et al. The Proyecto VER study observed that visual impairment was associated with a decrease in the quality of life among elderly patients, and that the severity of ocular diseases was related to the level of visual impairment. In relation to persons with no visual impairment, persons with bilateral mild and unilateral or bilateral moderate or severe visual impairment report greater difficulties in performing most vision-dependent daily activities, experience vision-related dependency and poorer vision-related mental health.
Ee Munn Chia et al. further disclosed that the impact of visual impairment on mental domains was much greater compared to co-existing medical conditions like stroke.
Therefore, data is needed on the effect of ocular diseases on vision-related quality of life among the elderly for the purpose of making recommendations for improved eye care with resultant improvement in their quality of life.
| Methods|| |
This was a descriptive cross-sectional study conducted at the Geriatric Outpatient Clinic of the University College Hospital, Ibadan, which is an established unit that attends to various health needs of the elderly i.e. individuals 60 years and above between February 2016 to May 2016.
A sample size of 427 was determined using Leslie-Keish statistical formula, in addition to an anticipated non-response rate of 10%. Ethical approval was obtained from the University of Ibadan/University College Hospital Ibadan ethical committee before commencement of the study. Permission was also obtained from the Head of the Geriatric Centre.
In addition, written informed consent was gotten from consecutive and eligible patients who met the following criteria i.e. best corrected visual acuity of worse than 6/12 and agreed to participate in the study. However, patients with acute or severe medical illness requiring urgent medical attention e.g. cerebrovascular accident, acute urinary retention, diabetic emergencies, and communication barrier like cognitive impairment, dementia were excluded from the study.
The study was carried out in line with the declaration of Helsinki for studies on human subjects.
Questionnaires in English (with translation to Yoruba) were administered to all participants (depending on their language preference) by only one trained assistant who recorded their socio-demographic data and the National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ 25) section. The examination section of the questionnaire was filled by the primary investigator. Presenting distance visual acuity of each eye was tested using an illuminated Snellen chart placed at a distance of six meters from the participant, while the near vision was assessed using a Jaeger near chart placed at 33cm in a well-lit room (with distant correction where applicable). Their vision-specific quality of life was assessed using the NEI VFQ-25.
The effect of ocular diseases on quality of life was assessed using the NEI VFQ-25. Original numeric values obtained from the survey were re-coded following the scoring rules according to the NEI VFQ-25 scoring algorithm. Each item was then converted to a 0 to 100 scale, so that the lowest and highest possible scores are set at 0 and 100 points respectively. Items within each subscale were averaged, and the final score represented the average of all items in the subscale that each respondent answered.
Data collected were entered and analyzed using the IBM Statistical Package for Social Sciences (IBM-SPSS) software version 20 (IBM SPSS Inc., Chicago IL, USA).
Summary statistics are presented as proportions for categorical variables, while quantitative variables were presented as means and standard deviation. Bivariate analysis including independent sample t-test and ANOVA was performed to test for association between quantitative continuous variables, while Chi square test was used to test the association between categorical variables.
All 11 sub-scales of the QoL including general health, general vision, ocular pain, near activities, distance activities, social functioning, mental health, role difficulty, dependency, colour vision, and peripheral vision were independently compared with gender using independent sample t-test, while ANOVA was used to compare the individual visual functioning sub-scales with the visual impairment sub-groups. t-test was also used to compare the mean difference between presence and absence of the individual ocular diseases.
To perform the multivariate analysis, a linear regression analysis was performed to ascertain the predictors of the various quality of life domains. The linear regression model included the variables that were statistically significant with the various outcome variable (quality of life domains) at the bivariate analysis level.
All test analysis was set at 5% level of significance (P < 0.05).
Mild Visual impairment was defined as visual acuity <6/12 to 6/18, Moderate Visual Impairment as <6/18 to 6/60, Severe Visual Impairment as VA <6/60 to 3/60 and blindness as <3/60.
Refractive error included myopia, hypermetropia and astigmatism.
Myopia was defined as spherical error of −0.50D or worse.,
Hypermetropia was defined as spherical error of +0.50D or worse.,
Astigmatism (minus cylinder format) was defined as a cylindrical error greater than 0.50D.
Presbyopia was defined as inability to read N8 with both eyes at a distance 40cm away from the subject.
Cataract was defined as opacification of the crystalline lens and graded using the WHO cataract grading system.
Cataract surgery was defined as surgical removal of lens in at least one eye, with or without intraocular lens implantation.
Glaucoma diagnosis was defined using International Society of Geographical and Epidemiological Ophthalmology (ISGEO) criteria as vertical cup-disc ratio ≥ 0.7 and or cup-disc asymmetry of ≥ 0.2.
Age Related Macula Degeneration (ARMD) was classified using the International Classification and Grading System for Age-Related Maculopathy and Age Related Macula Degeneration.
| Results|| |
A total of 427 consenting respondents participated in the study. The mean age of respondents was 71.6 ± 7.11 years, while most of the respondents 127 (29.8%) in this study were between the ages of 65 years to 69 years The sex distribution among the age groups is shown in [Table 1].
Distance visual acuity assessment showed that about one third of the patients had moderate visual impairment at presentation as shown in [Table 2].
The mean quality of life was highest in the colour vision sub domain (53.86 ± 28.91), followed by the distance activities sub domain (49.77 ± 2.35), while the quality of life was lowest in the general health subdomains (33.60 ± 18.78) as shown in [Table 3].
The comparison between the quality of life domains and visual impairment is presented in [Table 4].
The mean QOL scores were significantly lower among respondents with glaucoma across all QOL sub domains (P < 0.05) as shown in [Table 5].
The linear regression between quality of life domains and presence of ocular diseases among respondents is shown in [Table 6].
|Table 6 Linear regression showing the relationship between quality of life domains and ocular diseases|
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| Discussion|| |
In this study, there were more male participants (55.5%) than female participants (44.5%) which was at variance with the findings of Adepegba et al. (male 29.7%, female 70.3%), Adio (male 40%, female 60%) and Dreer et al. (male 16%, female 84%). However, a study by Ibrahim et al. in Saudi Arabia showed a higher male preponderance (male 62.7%, female 37.3%).
The age distribution of the patients was 60 to 91 years with a mean age of 71.6 ± 7.11 years, with more than half of the respondents in their 6th decade of life and about one tenth of them above 80 years of age. This mean age differs from Adio (85 ± 12.14 years) and Dreer (82 ± 7.7 years). Correspondingly, this upward trend of socio-demographic transformation suggests that there will be an increase demand for the limited healthcare services available due to the prospect of developing other health problems in addition to ocular morbidities.
Treatable and preventable causes of visual impairment accounted for majority of ocular morbidities among the elderly studied, which is akin to other studies done by Adepegba et al. and Kyari et al. Therefore, affordable and accessible healthcare services should be provided for them while not suffering any financial hardship according to the universal health coverage.
Despite a previous report by the Nigeria National Blindness and Visual Impairment Survey(NNBVS) done between 2005 and 2007 where 84% of blindness was found to be avoidable, no other major national survey has been carried out to evaluate the recommendations as well as various efforts to eradicate needless blindness and visual impairment in the country. Also, it is still disheartening that the elderly in addition to other systemic diseases still suffer from treatable visual impairment/blindness. This finding restates that if nothing is done to the health needs of this escalating aging population, the burden of ocular diseases and co-existing systemic diseases among them will continue to rise, while also stretching the limited healthcare services available.
In this study, visual impairment was found to negatively affect their quality of life across all its domains (P < 0.05). This finding was similar to studies done by Bekibele in Nigeria,, Nirmalan et al. in India and Broman et al. in the United States where diminishing quality of life across all domains were found to be associated with worsening visual impairment. Also, visual impairment negatively impacts the overall well-being and functional status of affected the elderly thus incapacitating them from performing independent daily tasks. This finding is similar to findings by Gureje et al. and Laforge et al. The presence of ocular diseases in conjunction with other systemic diseases and possible limited financial resources further worsens the physical and psychosocial well-being of affected individuals and care-givers at large.The mean quality of life (QoL) scores was significantly lower among respondents with ocular diseases across all QoL sub domains (P < 0.05), especially glaucoma and ARMD. In the Barbados eye and Proyecto VER studies, glaucoma was reported to affect QoL scores across all domains. This may be associated to the irreversible nature of blindness of the disease, as well as the loss of peripheral vision loss and subsequent central vision loss at an advanced stage.
The effect of cataract was significant in the general health, social functioning and peripheral vision domains. This was also supported by studies from a study by Nirmalan et al., as well as from the Barbados eye and Proyector VER. On the other hand, respondents who had undergone cataract surgery had relatively better QoL scores in the general health, ocular pain, near activities, distance activities and peripheral vision sub domains compared to those who had not undergone the procedure. This observation was also described by Ishii et al. and To et al. in their different studies.
Following the linear regression analysis between quality of life domains and ocular diseases, the general health and general vision sub-domain were significantly affected by glaucoma, while ocular pain, near activities, distance activities, social functioning, mental health, role difficulty and peripheral vision sub domains were significant positive predictors of glaucoma and ARMD. These findings show that the elderly will find it challenging performing their vision-dependent daily activities, with further deterioration of their overall functional status. Furthermore, this inability to independently perform daily tasks in a society where social welfare scheme is grossly non-existent will create more socio-economic burdens for family members and/or caregivers.
All these put together recommends that fully subsidised or free accessible cataract surgeries should be provided, in addition to establishing reachable and affordable all-inclusive health system for the elderly population, where qualitative healthcare services can be gotten regardless of their social status with the aim of improving their overall quality of life.
- This is a hospital-based study which is not likely to give a true prevalence of the ocular diseases and quality of life as compared to a population-based study.
- Time constraints − a longer study period would have helped for the assessment of their quality of life after intervention.
- Factors such as economic status of participants and cost of eye care services were not assessed in this study. This could have influenced previous utilization of eye care services.
- Presence of other associated systemic diseases associated with old age could have had an effect on their quality of life.
| Conclusion|| |
This study has revealed the undesirable effect of ocular diseases on vision-related quality of life across all its domains. Furthermore, worsening quality of life with probable additional systemic diseases reiterates the need to take care of the elderly population for optimal visual function and desirable quality of life.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]