Aging & Mental Health, November 2005; 9(6): 563–570
ORIGINAL ARTICLE
The effect of rehabilitation on depression among visually disabled older adults
A. HOROWITZ, J. P. REINHARDT, & K. BOERNER Lighthouse International, New York, USA
(Received 21 October 2004; accepted 30 November 2004) Abstract There has been a great deal of interest in identifying the impact of rehabilitation on psychological well-being, as well as functional ability, among elders with disabilities, but empirical data remain limited. This descriptive study of participants in vision rehabilitation service examines the effect of specific vision rehabilitation services (low vision clinical services, skills training, counseling, optical device use, and adaptive device use) on change in depression among a sample of older adults with age-related vision impairments. Participants (N ¼ 95) were interviewed at application for services and then approximately two years later. Findings from hierarchical regression analyses indicated that low vision clinical services, counseling, and use of optical devices, in separate models, each significantly contributed to a decline in depression, after controlling for age, health status, vision status, functional disability, as well as baseline depression. When all service variables were entered into the same equation, they explained an additional 10% of the variance in change in depression. Given the well documented robust relationship between disability and depression, findings point to the influence of vision rehabilitation interventions on both physical and psychological functioning, and underscore the need for future, controlled research on rehabilitation service models that address mental health issues.
Introduction Dealing with the disabling effects of a chronic impairment in old age constitutes a major adaptational challenge for older adults, and can increase the risk of subsequent mental health problems (Bruce, 2001). In fact, disability has been identified as the ‘hallmark’ of depression among older adults (Lebowitz et al., 1997). A potential benefit of rehabilitation services lies in reducing the risk of depression by helping the older person with a disability maintain or regain a certain degree of independent functioning, as well as by maximizing a sense of self-efficacy and control over one’s life. Age-related vision loss has been identified as the second most common disability among middle-aged and older adults (National Centre for Health Statistics, 1993), with the proportion of adults age 65 and older who report a vision impairment ranging from 15 to 20% (Crews & Campbell, 2001; Lighthouse Inc., 1995; Reuben, Silbey, Damesyn, & Moore, 1999). Age-related vision impairment typically results from the major age-related eye diseases (i.e., macular degeneration, cataract, glaucoma, and diabetic retinopathy), and is characterized by a gradual and continual deterioration. Rather than
resulting in total blindness, these conditions typically leave the older adult with partial sight or ‘low vision’, defined as a permanent vision impairment that is not correctable by spectacles, contact lenses, or medical or surgical intervention (Raasch, Leat, Kleinstein, Bullimore, & Cutter, 1997). Regardless of the severity of the loss, there is extensive evidence attesting to the profound impact vision impairment has on everyday functioning and interaction with the physical and social environment, as well as its strength as a predictor of functional decline over time (for reviews, see Burmedi, Becker, Heyl, Wahl, & Himmelsbach, 2002a; Horowitz, 2004; Wahl & Oswald, 2000). In turn, the negative impact of vision loss on functional ability and social activities has been shown to put individuals at significant risk for depression and poorer perceived life quality, even more so than is the case of other common age-related disabilities (for reviews, see, Burmedi, Becker, Heyl, Wahl, & Himmelsbach, 2002b; Horowitz, 2004; Horowitz & Reinhardt, 2000). Several studies suggest that approximately one-third of older adults who are visually impaired experience clinically significant depressive symptomatology (Brody et al., 2001; Horowitz & Reinhardt,
Correspondence: Amy Horowitz, DSW, Senior Vice President for Research, Director, Arlene R. Gordon Research Institute, Lighthouse International, 111 East 59th Street, New York, New York, 10023, USA. Tel: þ 1 212 821 9525. Fax: þ 1 212 821 9706. E-mail:
[email protected] ISSN 1360-7863 print/ISSN 1364-6915 online ß 2005 Taylor & Francis DOI: 10.1080/13607860500193500
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2000; Horowitz, Reinhardt, Boerner, & Travis, 2003; Reinhardt, 1996; Rovner & Casten, 2002). Geriatric rehabilitation, including vision rehabilitation, focuses on maintaining and optimizing current levels of functioning and reducing the disabling functional and psychosocial effects of chronic disease. Vision rehabilitation for adults with age-related vision impairments is typically community-based and may involve one or more of a range of services including: low vision clinical services (i.e., assessment of remaining visual function, prescription of optical and/or adaptive devices and supervision of training in the use of these devices by specially trained ophthalmologists or optometrists); rehabilitation teaching services (i.e., instruction in skills of daily living for personal care and home management, as well as training in the use of optical and adaptive devices); orientation and mobility training (i.e., instruction in developing an awareness of oneself in relation to one’s surroundings and safe travel techniques); and counseling and support groups that are designed specifically to address the emotional aspects of a vision loss and to facilitate psychosocial adaptation to the disability (Stuen & Faye, 2003). There has recently been a great deal of emphasis on the importance of, and need for, outcome research in vision rehabilitation services, not only in terms of specific visual functions (e.g., reading speed) and overall functional ability in daily activities, but also in terms of more global indicators of well-being and quality of life (Raasch et al., 1997; Stelmack, 2001; Watson, 2001). Given the high risk of depression among visually disabled elders, the potential effect of vision rehabilitation on depressive symptomatology has been especially emphasized. In fact, a recent research agenda developed by the American Geriatrics Society underscores the need to address the question of whether low vision rehabilitation reduces the severity, incidence, and prevalence of several related health conditions, among which depression is specifically highlighted (Lee & Coleman, 2004). However, empirical evidence regarding the effects of a variety of vision rehabilitation interventions on the mental health status of visually impaired adults remains limited and contradictory. Several studies, based on relatively small samples, have reported either no effect or only non-significant trends towards reduced levels of depression among older adults following various models of vision rehabilitation (Amaral & Ringering, 1988; Bernbaum, Albert, & Duckro, 1988; Griffin-Shirley, 1994; Robbins & McMurray, 1988). There have been clinical reports of the positive effects of social support interventions for older adults with visual impairments in terms of participant satisfaction and perceived benefit, but little formal evaluation (Kleinschmidt, 1996; McCulloh, Crawford, & Resnick, 1994).
Other studies using standardized measures, however, have reported positive findings regarding the effect of vision rehabilitation on improved mental health status. For example, Dodds, Flannigan and Ng (1993) reported reduced depression and anxiety, as well as increased self-efficacy, improvements in self-image, more positive attitudes about visual impairment, and a higher sense of control following a 10-week, residential vision rehabilitation program for visually impaired adults. Horowitz, Leonard and Reinhardt (2000), in a study of almost 400 older adults with vision impairments in a group intervention program that encompassed both skills training and support groups, found significant positive effects on a number of psychosocial indicators including depression. Other intervention research with visually impaired adults, incorporating no-treatment comparison groups, have reported improved mood, declines in psychological distress, and declines in depressive symptoms following treatment (Birk et al., 2004; Brody et al., 1999). One limitation of these studies, however, is that they do not specifically look at the various components of vision rehabilitation service programs for differential effects on psychological outcomes. Therefore, it is typically not possible to identify which aspects of a multi-service rehabilitation program were more or less powerful in determining outcomes. Further, most rely on immediate posttreatment measurement of outcomes, and thus offer little evidence of the long-term benefits of vision rehabilitation interventions. Yet, earlier analyses of the data from the study reported in this article documented that use of some rehabilitation, versus no utilization, predicted declines in depressive symptomatology over time among elderly rehabilitation applicants, even after controlling for age, impairment severity, health status, functional disability, and quality of social support (Horowitz et al., 2003). In sum, in addition to improved functional independence, more generalized quality of life indicators are being promoted as indicators of rehabilitation success. Psychological well-being, and specifically depression, represents an important outcome indicator in this context. However, more research evidence is needed, not only to better understand both the short and long-term effect of vision rehabilitation on mental health indicators, but also to identify which type of rehabilitation service, including the use of optical and adaptive aids, may be especially beneficial. Thus, the purpose of the present descriptive study is to examine the effect of various types of vision rehabilitation service on depressive symptoms in a group of elders with age-related vision loss who sought rehabilitative services. As described earlier, these services include low vision clinical services, skills training (rehabilitation teaching and orientation and mobility instruction); counseling, use of optical
Rehabilitation and depression in older adults
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devices, and use of adaptive devices. Specifically, the primary research questions addressed in the present study are: (1) To what extent does utilization of specific types of vision rehabilitation services between Time 1 and Time 2 each predict change in depression over time, after accounting for age and indicators of health and impairment? and (2) What is the combined strength of vision rehabilitation services in predicting change in depression over time?
more than half (57.9%) rated their health as either excellent or good, while 28.4% rated it as fair and 13.7% reported that they had poor or very poor general health.
Methods
Age. Continuous variable reflecting age on last birthday at baseline.
Sample The larger research project involved a two-phase study of older persons, age 65 and older, with a recent vision impairment who had applied to a vision rehabilitation agency. Details of the sample and methodology have been reported in Horowitz et al. (2003) and are summarized here. Data were collected via in-depth, in-person interviews taking approximately 60–90 minutes to complete. Baseline data (Time 1) were collected prior to service use and follow-up (Time 2) was conducted approximately two years later (between 20 and 27 months). Ninety-five of the original 155 baseline participants were reached at follow-up; 17% had died, 15% refused, and 7% could not be reached or were either too cognitively or hearing impaired to participate. Thus, 80.5% of the eligible respondents (95 of 118) participated at Time 2. Analyses comparing respondents (n ¼ 95) to non-respondents (n ¼ 60) at followup did identify an inclusion bias towards those who had relatively better physical and mental health at baseline (Horowitz et al., 2003). This situation, unfortunately, is not unusual in longitudinal studies of disabled elders (Beekman et al., 2002; Thompson, Heller, & Rody, 1994), and indicates that those who had initially higher rates of disability and depression were more likely to be lost to follow-up. The age of the follow-up sample (n ¼ 95) ranged from 65–89 years at baseline, with an average age of 76.9 years. More than half (56.8%) were female, 78.6% were White, only 42.1% were married, but 62.1% lived with others rather than alone. Over half of the participants (54.7%) had at least a high school diploma. As is typical with vision impairments due to age-related eye diseases (e.g., macular degeneration, glaucoma, cataract), none of the participants were totally blind. However, 57% had severe vision impairments with best-corrected distance acuity of 20/200 or worse, which is the criterion for legal blindness. These elders are typical of older samples in that they have multiple, comorbid conditions in addition to their vision problems. Respondents reported, on average, three concurrent health conditions, with the most common being arthritis, high blood pressure, circulation trouble, heart trouble and diabetes. At the same time,
Measures Control variables (age, health status, vision status, and functional disability) were all measured at baseline:
Health status. Self-rated health was rated on a five-point scale ranging from excellent (5) to very poor (1). Vision status. The Functional Vision Status Questionnaire (Horowitz, Teresi, & Cassels, 1991; Horowitz, 1998), a 15-item index, was used to assess subjective impairment severity. Items assess whether or not difficulty is experienced in specific functional areas (e.g., reading newspaper print, seeing price labels, and recognizing faces across a room). Potential scores range from 0 to 15, with an observed mean of 10.3 (SD ¼ 3.1) at baseline and a Cronbach’s alpha of 0.78. Functional disability. A modified version of the OARS Multidimensional Functional Assessment Questionnaire (Center for the Study of Aging and Human Development, 1975) was used to assess the elder’s disability in Activities of Daily Living (ADL). This measure included seven personal and 11 instrumental activities of daily living. Four items were added to this scale that specifically address functional tasks that may be affected by vision loss (ability to get around in unfamiliar places, to identify coins and bills, to identify one’s clothing, and to locate food on one’s plate). Items were assessed on a three-point rating scale (0 ¼ does task with no difficulty, 1 ¼ with difficulty, or 2 ¼ cannot do task without help). The mean ADL score at Time 1 was 8.8 (SD ¼ 6.6), with a Cronbach’s alpha of 0.86.
Vision rehabilitation service utilization Three dichotomous variables were created to indicate whether or not the following services were received: low vision clinical services, skills training (rehabilitation teaching [RT] and/or orientation and mobility [OM]), and counseling. It should be noted that the types of services received are determined on an individual basis, and are a function of both the rehabilitation professional’s assessment and the older adult’s expressed needs and willingness to accept services. Two additional variables measured the use
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of vision rehabilitation equipment: number of optical aids used (e.g., magnifiers, telescopes, special sunglasses) and number of adaptive aids used (e.g., talking books, large print reading materials, large print telephone dial, talking watches and clocks, special lighting).
Depressive symptoms The widely used 20-item Center for Epidemiological Studies Depression Scale (CES-D, Radloff, 1977) was used to assess respondents’ depressive symptoms (e.g., feelings of worthlessness, psychomotor retardation) rated on a four-point scale ranging from less than one day to 5–7 days during the past week (alpha ¼ 0.89). Depression was measured at both time points; the mean score at Time 1 was 12.3 (SD ¼ 10.9) and at Time 2, 11.8 (SD ¼ 11.0).
Data analyses Descriptive analyses were conducted to examine the extent of service utilization by participants. Bivariate and hierarchical regression analyses were conducted to examine the contribution of both specific and combined rehabilitation service utilization on depressive symptoms, controlling for age and baseline health, vision, and functional status. Because we were interested in change in depression between baseline and the two-year follow-up, we entered baseline CES-D scores in the first step along with the other control variables in all analyses. Six different regression models were examined: five that entered one of the service types or equipment use variables in the second step in order to identify its unique contribution to change in depression, and the last which included all rehabilitation variables in the second step in order to also identify the overall additive effect of rehabilitation services on change in depression in terms of total percent of variance explained. Results As reported in Horowitz et al. (2003), one-third (33.7%) of all participants met the criteria for significant depressive symptomatology at baseline, using the recommended cut score on the CES-D of 16 and higher, and one-fourth (25.3%) did so at follow-up, approximately two years later. There was both stability and change in depression status among participants. That is, while more than three-fifths (62%) were never depressed and one-fifth (21%) were consistently depressed, 13% had a remitted depression from baseline to follow-up and 4% were newly depressed at follow-up. The data also indicated variability in the types of services utilized. Although all participants had applied or had been referred to the organization for vision rehabilitation, not all followed up on
their application. By self-reports, 81% of participants received some service and 19% received none. Since all participants were new applicants with a relatively recent vision problem, it was not unexpected that low vision clinical service was the most commonly used vision rehabilitation service, with over three-fourths (78%) reporting utilization. Low vision services focus on maximizing use of remaining vision with optical devices and are typically the gateway for mild or moderately impaired individuals into the vision rehabilitation system. Skills training (RT/OM) are generally engaged in by older adults with more severe vision impairments, and were reported by 30% of the participants. Counseling, as an adjunct to the more functional rehabilitation services, was received by 16% of the sample. Eighty percent of the follow-up participants were using at least one optical device by Time 2, with a range of 0–6, and an average of 1.9 devices per participant (SD ¼ 1.5). Approximately 60% were using some type of magnifier, with other devices including telescopes (7.4%) and absorptive lenses (30.5%). The number of adaptive aids used by participants by Time 2 ranged from 0 to 8, with 86% using at least one adaptive aid and an average of 2.3 devices (SD ¼ 1.9) per participant. The most commonly used adaptive aid was a large print telephone dial used by 40% of participants, followed by talking books (39%) and special lighting (36%). Results from the bivariate analyses are presented in Table I. Higher levels of depressive symptoms at Time 2 were significantly associated with older age, poorer self-rated health, and greater functional disability at baseline, in addition to the expected significant association with baseline depression. Receiving low vision services and skills training were significantly associated with fewer depressive symptoms at Time 2, as were using a greater number of optical and adaptive aids. However, there was no bivariate relationship with receiving counseling services. The hierarchical regression analyses for the individual services are presented in Table II. The control variables entered in Step 1 of each equation explain
Table I. Correlations of predictor variables with depression T2. Variables
Depression T2
Depression T1 Age Gender (female) Health Functional vision loss Functional disability Low vision service (yes) Skill training (yes) Counseling (yes) Optical aids (#) Non-optical aids (#) Pairwise N ¼ 95; *p < 0.05; **p < 0.01; ***p < 0.001.
0.67*** 0.25* 0.10 0.45*** 0.13 0.27** 0.31** 0.22* 0.07 0.33** 0.24*
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Rehabilitation and depression in older adults Table II. Hierarchical regressions for effects of five individual rehabilitation variables on depression at T2. Model 1 Step 1: Control variables Depression T1 Age Gender (female) Health Functional vision Functional disability Step 2: Rehabilitation variables Low vision service (yes) Skill training (yes) Counseling (yes) Optical aids (#) Non-optical aids (#) Total R2
R
Model 2 2
0.48*** 0.54*** 0.13 0.04 0.18* 0.01 0.02
Model 3
R
2
0.48*** 0.55*** 0.08 0.01 0.19* 0.02 0.00
R
0.48*** 0.59*** 0.09 0.01 0.19* 0.07 0.00
0.02þ
0.05**
R
Model 4 2
Model 5 2
0.48*** 0.55*** 0.07 0.05 0.20* 0.03 0.03
0.03*
R2 0.48***
0.55*** 0.08 0.02 0.20* 0.02 0.00 0.03*
0.01
0.22** 0.15þ 0.18* 0.18* 0.08 0.53***
0.50***
0.51***
0.51***
0.49***
Listwise N ¼ 92, R2 ¼ R2 change. þp < 0.10 ; *p < 0.05; **p < 0.01; ***p < 0.001.
Table III. Hierarchical regression for total effect rehabilitation variables on depression at T2.
Step 1: Control variables Depression T1 Age Gender (female) Health Functional vision Functional disability Step 2: Rehabilitation variables Low vision service (yes) Skill training (yes) Counseling (yes) Optical aids (#) Non-optical aids (#) Total R2
B
SE
R2
0.53 0.16 0.84 10.79 0.14 0.01
0.09 0.14 10.69 0.97 0.31 0.17
0.53*** 0.09 0.04 0.16þ 0.04 0.01
0.48***
50.12 10.98 20.95 10.24 0.39
20.17 20.14 20.47 0.58 0.52
0.19* 0.08 0.10 0.17* 0.07
0.10**
0.57***
Listwise N ¼ 92, R2 ¼ R2 change. þp < 0.10 ; *p < 0.05; **p < 0.01; ***p < 0.001.
48% of the variance in depression status at Time 2, with only baseline depression and health status maintaining independent significant relationships. Thus, the potential contribution of age, vision status, and functional disability at baseline to change in depression between baseline and Time 2 appears to be subsumed by their relationships with baseline depression and health status. The results of the subsequent analyses indicate that several of the individual vision rehabilitation service variables are significant in contributing to a decline in depressive symptoms over time. Specifically, use of low vision clinical services significantly explained an additional 5% of the variance after baseline depression and other control variables are in the equation, and counseling and use of optical devices each significantly explains 3% of the variance. However, the use of adaptive aids does not contribute unique variance, and there was only a non-significant ( p ¼ 0.08) trend in regard to the relationship between skill training services (RT and OM) and change in depression. When all service variables are entered in the final regression analysis
(see Table III), their combined effect produces a significant 10% change in the variance of Time 2 depression, after controlling for baseline depression, age, and other health indicators, with low vision clinical services and use of optical aids maintaining significance within the step. Discussion Findings from these analyses confirm that depression is a prevalent and often persistent problem among older adults with age-related vision impairments. One-third of our participants reported clinically significant depressive symptoms at baseline; onefourth did so at the two year follow-up, and 21% experienced depression at both points in time. These rates are as high, or higher, than those documented among medically ill elders and those with other common age-related disabilities (Blazer, 2003). The fact that the participants lost to follow-up were those with relatively greater levels of both disability and depressive symptoms at baseline, means that even with these high rates, we are likely underestimating
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the prevalence of depression in this population of visually disabled older adults. Our analyses focused on examining the contribution of various components of a vision rehabilitation program to predicting change in depression over time among older adults with recent age-related vision impairment. We found that counseling services, low vision clinical services (i.e., assessment of residual vision and prescription of optical devices), as well as the participants’ reported use of these devices, were significant contributors to a decline in depressive symptoms over time, whereas skills training and use of adaptive devices were not. Overall, the combined contribution of rehabilitation service use, explaining a unique 10% of the variance in depression change, was noteworthy given that almost half of the variance had already been accounted for in the first step of the analyses. These findings are suggestive of the importance of vision rehabilitation in combating the psychological as well as physical effects of late life visual disability. We would propose that the influence of low vision services and use of optical aids on depression status may be a function of the timing of service application and intervention, as well as the type of intervention. Low vision clinical services are typically the first rehabilitation service used by older adults who are experiencing an initial vision problem due to an age-related eye disease. These adults are often coping with the emotional impact of having been given a diagnosis by an ophthalmologist and then told that nothing more can be done—at least medically or surgically. On the other hand, the message that comes from the low vision specialist is often one that offers hope; not of restoring vision, but of being able to continue valued activities with the appropriate use of optical devices such as magnifiers, telescopes, and computer assisted magnification systems. This intervention is often very successful in providing older adults with devices and alternate systems that allow them to continue reading for pleasure as well as for social activities (e.g., reading menus, playing cards) and activities of daily living (e.g., reading street signs, medicine bottles). Since one of the most devastating consequences of a vision loss for older adults is losing the ability to read (Ryan, Anas, Beamer, & Bajorek, 2003), this intervention can clearly have a major impact on life quality. The fact that skills training and use of adaptive devices were not significant in influencing long-term change in depression is more difficult to interpret. However, these services tend to be used by the older adults with more severe vision impairments who need to learn compensatory methods for accomplishing activities of daily living (e.g., using talking books instead of device-assisted reading, or mobility aids such as the long white cane). Importantly, while skills training and use of adaptive devices can result in the ability to continue some
aspects of conducting desired tasks, it may not be as desirable as still being able to use one’s remaining vision when possible. For example, the ability to read text can be regained by a visually impaired person who receives low vision services and has training in the use of powerful magnification devices. Alternately, use of such devices may not be possible under conditions of severe vision loss. Listening to talking books or having text read out loud may become an option, but not enough to influence one’s overall adjustment in terms of mental health. Thus, being more disabled initially, they may also then be more likely to experience greater declines in both visual and physical functioning over time, which would have a negative effect on mental health status. While there is an emerging literature that recognizes the importance of identifying and treating depression among persons seeking vision rehabilitation services, there remains controversy regarding the timing of such interventions. For example, Leinhaas and Hedstrong (1994) describe a model of low vision services that involves assessment of all patients by social workers for depressive symptoms. Those who meet diagnostic criteria are referred for psychiatric consultation and the low vision intervention delayed pending treatment for depression. The rationale for this treatment approach is that depressed low vision patients have been clinically observed to have less successful low vision outcomes, and thus, treatment for depression must precede rehabilitation for the vision impairment. Others have argued that vision rehabilitation services that improve functional disability also facilitate enhanced self-efficacy and empowerment and thus impact on psychological well-being (Warren & Lampert, 1994). To date, we know of no systematic evaluation of rehabilitation services that have tested these competing hypotheses. While our study was limited by its observational nature with a pre/post-test design which examined the natural course of rehabilitation interventions, rather than a controlled, randomized, prospective study with a standardized treatment model, we believe that our findings can provide preliminary support for both positions. That is, both the functionally oriented rehabilitation services (low vision services) and the specific psychosocial intervention (counseling) seemed to contribute to a decline in depression over time. We would argue that it is not an ‘either/or’ proposition, but one that will differ based on the characteristics and needs of the individual. Future studies with controlled, randomized, prospective designs are needed to test and contrast different models of vision rehabilitation interventions in order to better understand the pathways by which rehabilitation influences psychological well-being. The evaluation of service models that differentially, in both timing and type, integrate a mental health
Rehabilitation and depression in older adults component is important in order to identify the characteristics of individuals that make them more or less successful on various service paths. This information is critical in order to optimize both functional and psychosocial rehabilitation outcomes for older adults with visual disabilities.
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