Moran CORE

Open source ophthalmology education for students, residents, fellows, healthcare workers, and clinicians. Produced by the John A. Moran Eye Center in partnership with the Spencer S. Eccles Health Sciences Library

Search Moran CORE

Visual Impairment in an Aging Population

Basic Ophthalmology Review / Additional Resources

 

Title: Visual Impairment in an Aging Population

Authors: Michael Jensen, MD., Brian Stagg MD

Date: 9/5/2024

Keywords/Main Subjects: Aging, visual impairment

Summary: Visual impairment and eye disease disproportionately affect older adults ≥65 years. With the growing, aging population, the prevalence of VI is expected to double by 2050. Projected shortages of ophthalmologists indicate the work force will likely be inadequate to meet the growing demand. VI prevalence and access to care significantly impacts public health planning, Medicare disbursements, ocular disease, and common co-morbidities such as dementia and depression.

 

Introduction

The prevalence of vision impairment (VI) and visual dysfunction disproportionately affects older adults.1​ Recent studies show that 1-in-4 adults over age 71 have visual impairment, defined as VA >20/40.2,3​ Additionally, 10% have visually significant reduction in contrast sensitivity, and another 10% have distance vision impairment. The prevalence of VI increases to 37.9% of adults 85-89 and 46% in adults ≥90 years.3​ By 2050, it is estimated there will be 61million people (about twice the population of Texas) legally blind worldwide, and 474 million with moderate to severe VI, the majority of whom will be over age 65.​11

Currently in the US, there are an estimated 60 million adults over 65 years, however, the number of older adults is expected to increase to 78.3 million by 2040 and 82 million by 2050.​4​ This amounts to an increase in total share of the population from 17% to 23%. Over that same time, life expectancy will increase, from 73.6 years to 78.2 years, which will increase the proportion of adults in the 8th and 9th decade of life which is when vision impairment tends to be more severe and disabling.​4​ An expanding, aging population is the primary driver of the growing burden of VI. The resulting demand for eye health services is expected to increase accordingly and current projections forecast a significant shortage of ophthalmologists by the year 2035.​5​ Of 38 specialties, ophthalmology is projected to rank 37th in terms of adequate physician coverage.​5

 

By the Numbers

In 2024, the Department of Human and Health Services and Centers for Medicare and Medicaid Services (CMS) released physician-level Medicare disbursement data.​6 The report contains data from 2012 detailing the quantity and type of health care provided under the Medicare Part B fee-for-service (FFS) program from all 50 states, Washington DC, and Puerto Rico. The report found that ophthalmology as a specialty received the second highest aggregate Medicare payments at just over 5 billion dollars. Most of the payments were to ambulatory surgical centers for cataract surgery and anti-vascular endothelial growth factor (anti-VEGF) injections for treatment of neovascular age-related macular degeneration (ARMD) and other retinal diseases. Ophthalmology’s place in second is not surprising given historical trends dating back to the 1980’s.​7​ A similar study published in 1992 found that ophthalmology was the largest recipient of Medicare specialty disbursements.​7

Cataracts and ARMD are among the most common eye diseases in older adults. In 2010, an estimated 50% of adults ≥75 years had visually significant cataracts. NIH estimates in 2050 there will be 50.2 million people in the United States alone that will have visually significant cataracts.​8 In addition to cataracts, 20% of adults ≥75 years have early AMD. The prevalence increases to 30% by age 85. Late-stage AMD is relatively rare given modern therapeutics, but prevalence increases dramatically with age, from 3-4% at age 75, 10% at age 80, up to15% at age 90.9

Glaucoma is another ocular disease more common in older adults. Glaucoma prevalence ranges 4-8% for adults 65-75, and 7-12% over 80 years.​10,11​ Glaucoma is the leading cause of irreversible blindness and typically has an insidious onset over many years where the patient has no perception of their reducing vision. Topical medications in the form of eye drops are the most common 1st line treatment. Application of eye drops can be difficult for older adults due to physical limitations secondary to loss of the natural lordosis of the spine, poor vision, reduced coordination, and overall medication burden. However, non-adherence rates by age vary across studies with some studies showing reduced adherence, increased adherence, or no difference in adherence based on age.12-14​ Older adults do tend to report higher rates of difficulty with eye drops and are more likely to refill prescriptions before the refill date due to wastage.​15

A population-based study from 2021 showed that prevalence of diabetic retinopathy (DR) to be 30% in adults with diabetes age ≥75, of which 8-10% have vision threatening DR.​16​ These results are similar to a meta-analysis in 2004 which found the prevalence of DR to range between 10-40% and vision threatening DR to range between 2-10% in adults ≥75 years.​17​ With rates of diabetes projected to increase, there may be a resulting increase in the prevalence of DR and vision threatening DR.​18

Dry eye occurs in 5-30% of adults over age 65 and prevalences increases with age. With aging there are changes in tear quality, increased tear film evaporation, neurodegenerative disease such as Parkinson’s disease which decrease tear production, and increased inflammation and oxidative stress which also disrupts tear film production.19​ Dry eye is a risk factor many other ocular diseases, especially corneal disease. Uncorrected refractive error is another common cause of VI. 17.8-23.60% of adults ages 65-79 have ≥ +3 D of hyperopia. Myopia, however, is inversely correlated with age.20

There are numerous other causes of VI that are rare in the population over all but more common in older adults. For example, the median age of diagnosis for uveal melanoma is approximately 62 years and the peak range for diagnosis is between 70 and 79 years.​21 Retinal detachment, optic neuropathy, and dermatochalasis are other examples of ocular disease more prevalent in older adults.22-24

 

Multi-Morbidity

Visual impairment has significant consequences on the health of older adults apart from their vision. Cardiovascular disease, diabetes, hypertension, hearing impairment, COPD, kidney disease, and stroke are more common in adults >65 years with vision impairment compared to age matched, visually healthy controls.25,26​ Poor vision also effects how a person with chronic disease perceives their health. Self-reporting studies show that patients with VI report their health as worse compared to disease-matched controls without VI.26​ A recent meta-analysis of 28 studies found that the hazard of all-cause mortality was higher in people with moderate to severe VI compared to those with normal vision or mild VI.​27

A recently published nationally representative study with objective visual measurements found that the prevalence of falls is associated with decreased contrast sensitivity but not with near or far distance visual acuity.28​ Currently, contrast sensitivity screening is not included in the NIH Toolbox of recommended visual screening tests, or the Center of Disease Control’s (CDC) Stopping Elderly Accidents, Deaths, & Injuries (STEADI) algorithm.29,30 More research needs to be done to assess the utility of regular contrast sensitivity screening by general practitioners and geriatricians.

Untreated poor vision has been identified as a contributing factor to dementia later in life. Rogers and colleagues found that the risk of developing dementia was 56% lower in participants who received an indicated eye procedure than those without and that the risk of dementia decreased by 64% in those with at least one visit to an ophthalmologist.31​ Another study using data from the 2018 Health and Retirement Study estimates that more than 100,000 cases of dementia could have been prevented through healthy vision.32​ VI is reported to be as high as 74% in patients with cognitive decline.​33​ VI and visual symptoms lead to a positive feedback cycle of more frequent and severe neuropsychiatric symptoms, increased hospital services, decreased social interaction, and increased conflict and exhaustion for caregivers.​33

Depression and depressive symptoms are also more common in older adults with sensory difficulty, including VI, compared to age-matched controls.1834​ In a recent study, visual difficulty was found to have a hazard ratio of 1.25 for incidence of depressive symptoms, compared to those without sensory difficulty. The cause is likely multi-factorial including increased withdrawal from social activity, loneliness, inability to participate in activities that promote wellness and wellbeing, discrimination and stigma.34,35

 

Conclusion

Visual impairment and eye disease disproportionately affect older adults ≥65 years. With the growing, aging population, the prevalence of VI is expected to double by 2050. Projected shortages of ophthalmologists indicate the work force will likely be inadequate to meet the growing demand. VI prevalence and access to care significantly impacts public health planning, Medicare disbursements, ocular disease, and common co-morbidities such as dementia and depression.

 

References

  1. Bourne R, Steinmetz JD, Flaxman S, et al. Trends in prevalence of blindness and distance and near vision impairment over 30 years: an analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021;9(2):e130-e143. doi:10.1016/S2214-109X(20)30425-3
  2. ICD-11 for Mortality and Morbidity Statistics 9D90 Vision impairment including blindness. Accessed August 12, 2024. https://icd.who.int/browse/2024-01/mms/en#1103667651
  3. Killeen OJ, De Lott LB, Zhou Y, et al. Population Prevalence of Vision Impairment in US Adults 71 Years and Older. JAMA Ophthalmol. 2023;141(2):197. doi:10.1001/jamaophthalmol.2022.5840
  4. 2023 National Population Projections Tables: Main Series. Accessed August 12, 2024. https://www.census.gov/data/tables/2023/demo/popproj/2023-summary-tables.html
  5. Berkowitz ST, Finn AP, Parikh R, Kuriyan AE, Patel S. Ophthalmology Workforce Projections in the United States, 2020 to 2035. Ophthalmology. 2024;131(2):133-139. doi:10.1016/j.ophtha.2023.09.018
  6. HHS Releases Physician-Level Medicare Data. Accessed August 13, 2024. https://www.cms.gov/newsroom/fact-sheets/hhs-releases-physician-level-medicare-data
  7. Frenkel M. Ophthalmology Is the Single Largest Recipient of Medicare Specialty Disbursements. Archives of Ophthalmology. 1992;110(2):168. doi:10.1001/archopht.1992.01080140018004
  8. Cataract Tables. Accessed August 12, 2024. https://www.nei.nih.gov/learn-about-eye-health/eye-health-data-and-statistics/cataract-data-and-statistics/cataract-tables
  9. Rein DB, Wittenborn JS, Burke-Conte Z, et al. Prevalence of Age-Related Macular Degeneration in the US in 2019. JAMA Ophthalmol. 2022;140(12):1202. doi:10.1001/jamaophthalmol.2022.4401
  10. Rudnicka AR, Mt-Isa S, Owen CG, Cook DG, Ashby D. Variations in Primary Open-Angle Glaucoma Prevalence by Age, Gender, and Race: A Bayesian Meta-Analysis. Investigative Opthalmology & Visual Science. 2006;47(10):4254. doi:10.1167/iovs.06-0299
  11. Zhang N, Wang J, Li Y, Jiang B. Prevalence of primary open angle glaucoma in the last 20 years: a meta-analysis and systematic review. Sci Rep. 2021;11(1):13762. doi:10.1038/s41598-021-92971-w
  12. Wolfram C, Stahlberg E, Pfeiffer N. Patient-Reported Nonadherence with Glaucoma Therapy. Journal of Ocular Pharmacology and Therapeutics. 2019;35(4):223-228. doi:10.1089/jop.2018.0134
  13. OLTHOFF C, SCHOUTEN J, VANDEBORNE B, WEBERS C. Noncompliance with Ocular Hypotensive Treatment in Patients with Glaucoma or Ocular HypertensionAn Evidence-Based Review. Ophthalmology. 2005;112(6):953-961.e7. doi:10.1016/j.ophtha.2004.12.035
  14. Tse AP, Shah M, Jamal N, Shaikh A. Glaucoma treatment adherence at a United Kingdom general practice. Eye. 2016;30(8):1118-1122. doi:10.1038/eye.2016.103
  15. Friedman DS, Okeke CO, Jampel HD, et al. Risk Factors for Poor Adherence to Eyedrops in Electronically Monitored Patients with Glaucoma. Ophthalmology. 2009;116(6):1097-1105. doi:10.1016/j.ophtha.2009.01.021
  16. Lundeen EA, Burke-Conte Z, Rein DB, et al. Prevalence of Diabetic Retinopathy in the US in 2021. JAMA Ophthalmol. 2023;141(8):747. doi:10.1001/jamaophthalmol.2023.2289
  17. The Eye Diseases Prevalence Research Group. The Prevalence of Diabetic Retinopathy Among Adults in the United States. Archives of Ophthalmology. 2004;122(4):552. doi:10.1001/archopht.122.4.552
  18. Ong KL, Stafford LK, McLaughlin SA, et al. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. The Lancet. 2023;402(10397):203-234. doi:10.1016/S0140-6736(23)01301-
  19. Sharma A, Hindman HB. Aging: A Predisposition to Dry Eyes. J Ophthalmol. 2014;2014:1-8. doi:10.1155/2014/781683
  20. Eye Diseases Prevalence ResearchGroup. The Prevalence of Refractive Errors Among Adults in the United States,Western Europe, and Australia. Archives of Ophthalmology. 2004;122(4):495. doi:10.1001/archopht.122.4.495
  21. Krantz BA, Dave N, Komatsubara KM, Marr BP, Carvajal RD. Uveal melanoma: epidemiology, etiology, and treatment of primary disease. Clinical Ophthalmology. 2017;Volume 11:279-289. doi:10.2147/OPTH.S89591
  22. Jacobs LC, Liu F, Bleyen I, et al. Intrinsic and Extrinsic Risk Factors for Sagging Eyelids. JAMA Dermatol. 2014;150(8):836. doi:10.1001/jamadermatol.2014.27
  23. Saraf SS, Lacy M, Hunt MS, et al. Demographics and Seasonality of Retinal Detachment, Retinal Breaks, and Posterior Vitreous Detachment from the Intelligent Research in Sight Registry. Ophthalmology Science. 2022;2(2):100145. doi:10.1016/j.xops.2022.100145
  24. Hayreh SS. Ischemic optic neuropathy. Prog Retin Eye Res. 2009;28(1):34-62. doi:10.1016/j.preteyeres.2008.11.002
  25. Vision Impairment and Chronic Health Conditions. Accessed August 12, 2024. https://www.cdc.gov/vision-health/php/chronic-conditions-vision/index.html
  26. Crews JE, Chou CF, Sekar S, Saaddine JB. The Prevalence of Chronic Conditions and Poor Health Among People With and Without Vision Impairment, Aged ≥65 Years, 2010–2014. Am J Ophthalmol. 2017;182:18-30. doi:10.1016/j.ajo.2017.06.038
  27. Ehrlich JR, Ramke J, Macleod D, et al. Association between vision impairment and mortality: a systematic review and meta-analysis. Lancet Glob Health. 2021;9(4):e418-e430. doi:10.1016/S2214-109X(20)30549-0
  28. Jin H, Zhou Y, Stagg BC, Ehrlich JR. Association between vision impairment and increased prevalence of falls in older US adults. J Am Geriatr Soc. 2024;72(5):1373-1383. doi:10.1111/jgs.18879
  29. Varma R, McKean-Cowdin R, Vitale S, Slotkin J, Hays RD. Vision assessment using the NIH Toolbox. Neurology. 2013;80(11_supplement_3). doi:10.1212/WNL.0b013e3182876e0a
  30. STEADI – Older Adult Fall Prevention Algorithm. Accessed August 15, 2024. https://www.cdc.gov/steadi/index.html
  31. Rogers MAM, Langa KM. Untreated Poor Vision: A Contributing Factor to Late-Life Dementia. Am J Epidemiol. 2010;171(6):728-735. doi:10.1093/aje/kwp453
  32. Ehrlich JR, Goldstein J, Swenor BK, Whitson H, Langa KM, Veliz P. Addition of Vision Impairment to a Life-Course Model of Potentially Modifiable Dementia Risk Factors in the US. JAMA Neurol. 2022;79(6):623. doi:10.1001/jamaneurol.2022.0723
  33. Zhang W, Roberts T V., Poulos CJ, Stanaway FF. Prevalence of visual impairment in older people living with dementia and its impact: a scoping review. BMC Geriatr. 2023;23(1):63. doi:10.1186/s12877-022-03581-8
  34. Killeen OJ, Xiang X, Powell D, et al. Longitudinal Associations of Self-Reported Visual, Hearing, and Dual Sensory Difficulties With Symptoms of Depression Among Older Adults in the United States. Front Neurosci. 2022;16. doi:10.3389/fnins.2022.786244
  35. Shakarchi AF, Assi L, Ehrlich JR, Deal JA, Reed NS, Swenor BK. Dual Sensory Impairment and Perceived Everyday Discrimination in the United States. JAMA Ophthalmol. 2020;138(12):1227. doi:10.1001/jamaophthalmol.2020.3982​ 

 

Faculty Approval by: Brain Stagg 

Copyright statement: Michael Jensen, Brian Stagg, ©2024. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/