Vision Loss and Depression in the Elderly

The emotional and functional consequences of sensory impairment in older persons have not been well studied despite the increasing prevalence of vision loss, in particular, and its substantial adverse effects. This review examines the impact of vision loss on psychological health, discusses factors that may reduce its negative effects, and describes new in terventions to help older people cope with eye diseases such as age-related macular degeneration (AMD).

AMD is the most common cause of legal blindness in the United States; it affects almost 10 million people.^1,2 It is caused by deterioration of the macular region of the retina and can lead to various pigment changes, either as geo graphic atrophy (dry AMD) or choroidal neovascularization (neovascular or wet AMD). Although the dry form is more common (85% of AMD cases), many cases eventually transition to the wet form. Both types cause visual distortions that predominantly affect central vision and interfere with activities such as reading and driving. Risk factors for AMD include age over 60 years, smoking, obesity, white race, family his tory, and female sex.

One large-scale study suggests that a specific vitamin/mineral formulation (C, E, beta-carotene, zinc, and copper) can slow the progression to advanced AMD in high-risk patients.³ Although newer pharmalogic treatments (eg, ranibizumab) effectively halt vision loss in some patients and may improve vision slightly, none can restore vision to premorbid levels. For many patients, rehabilitation may be the most effective option for improving vision function, that is, the ability to perform necessary daily tasks even without improving visual acuity. Low vision rehabilitation encourages the use of assistive aids and devices (large clock, magnifiers), alternative reading materials (audio books), strategies for circumventing vision loss (using brightly colored tape to highlight dials on appliances), and environmental modifications (use of contrast).

Vision loss and disability
The effect of AMD on a patient's life can be devastating because vision loss is one of the major contributors to loss of independence and diminished quality of life in older persons. Williams and colleagues⁴ interviewed 86 patients with AMD and found that their overall ratings of quality of life were sub stantially lower than those of visually intact older persons, older persons with severe chronic obstructive pulmonary disease, or patients with AIDS. Compared with older persons who have intact vision, the patients with AMD were 8 times more likely to have trouble shopping, 13 times more likely to have difficulty in managing finances, 4 times more likely to have problems with meal preparation, 9 times more likely to report difficulty with light housework, and 12 times more likely to have trouble using a telephone.⁵

Another study found that persons with impaired vision were almost twice as likely as unimpaired persons to experience a fall or a broken hip. They were 3 times as likely to have difficulty in walking, 3.3 times more likely to have trouble getting outside, 3.1 times more likely to have difficulty in managing their medications, and 3.5 times more likely to have problems with meal preparation.6 Vision loss in the elderly is a significant contributor to functional lim itations and reduced quality of life.

Vision loss and depression
Impaired vision can bring about a loss of independence, feelings of inadequacy, and a halt to activities and pas times that give life meaning and richness. Social isolation can arise from mobility restrictions (difficulty in driving, limited walking because of fear of falling), embarrassment about vision loss, and impairments in processing visual stimuli (reading nonverbal facial cues). Given the disabling effects of vision loss in older persons, it is not surprising that there is a high rate of psychological distress in this population. When patients who have AMD with unilateral blindness were com pared with those with bilateral legal blindness, those with unilateral blindness had greater emotional distress despite comparable levels of disability. The investigators speculated that the anticipation of future worsening vision faced by these patients is a source of great emotional anguish and fear.⁵

AMD is a significant risk factor for depressive disorders. In a study of 51 patients with new-onset AMD (diagnosed within 6 weeks) it was found that 33% met criteria for a depressive disorder at 6-month follow-up.⁷ Brody and colleagues⁸ obtained similar results (32.5%) in a study of 151 patients with AMD.⁸ These observed rates are more than twice those seen in noninstitutionalized elderly persons⁹ and are higher than or comparable to rates documented in other disabling diseases (coronary heart disease [16%], stroke [26%], cancer [25% to 38%]).10-12 De pression and its concomitant emotional distress have profound effects on vision-related disability.

Depression and disability
Depression in older persons often occurs in the context of declining physical health and activity restriction. In fact, common symptoms of late-life depression include a preoccupation with health symptoms, social withdrawal, relinquishment of leisure activities, impairment of activities of daily living (dressing, bathing) and instrumental activities of daily living (balancing checkbook, taking medications), and pain complaints. This depression is com monly described as a downward spiral whereby poor health leads to functional decline, which in turn leads to depression. Over time, functional decline and depression interact in such a way that each increasingly worsens the other.

This downward spiral as it pertains to vision loss was clearly demonstrated in a prospective cohort study of 51 older patients.⁷ Longitudinal analyses showed that worsening depressive symptoms predicted worsening function above and beyond that which was accounted for by decline in visual acuity. A com parison of patients in whom depression did or did not develop at 6-month follow-up showed that those with de pression were 8.3 times more likely to experience a significant decline in function even when the effects of visual acuity were controlled for. These findings illustrate that disability initially caused by vision loss was magnified once patients developed depression.¹³ Other studies have reported a similar pattern of results. For example, Brody and colleagues⁸ found that patients who were depressed reported greater disability than patients who were not. The findings of a study of 872 elderly subjects show that among those with impaired vision, depressive symptoms significantly increased the odds of functional impairment even when the effects of vision were controlled for.¹⁴

These studies highlight the fact that depression can negatively impact disability in patients with vision loss. Other research emphasizes the reverse relationship (the effect of vision-related disability on depression). Vision loss can force patients to abandon once-enjoyable activities (hobbies, crafts, read ing), which may further put them at risk for depression. In a 2002 study, we found that the relationship between vision loss in the elderly and depression is mediated by relinquishing a valued activity.¹⁵ In other words, vision loss leads to depression to the extent that important activities are no longer accomplished.

Subthreshold depressive symptoms can also have a profound adverse effect on functioning. This has been observed in the context of vision loss as well. Horowitz and colleagues¹⁶ reported functional disability ratings in 3 groups of older patients presenting for low vision rehabilitation services: (1) those with major depression; (2) those with subsyndromal depressive symptoms; and (3) those with no depression. The patients with depressive symptoms that did not meet criteria for a depressive disorder had levels of disability comparable to those with major depression; both groups had significantly greater disability than did subjects with no depression.

Our group recently examined the relationships between disability and min imal depressive symptoms in a sample of 206 nondepressed AMD patients whose average Hamilton Depression Rating Scale (HDRS) score was 2.2. The patients who were minimally depressed had decrements in vision function that could not be accounted for by the severity of their eye disease or general medical problems. They met no diagnostic criteria for depression, received no current or past treatment for depression, and had normal scores on the HDRS. Their mean HDRS score of 5.4 (SD, 1.7) was lower, in fact, than the HDRS score of 7 that indicates remission from depression in clinical trials of antidepressants. These data suggest that having even "a speck" of depression can be disabling.¹⁷

Treatment strategies
The relationships between depression and disability have important implications for depression treatment strategies. Decisions regarding when to intervene are often based on an assessment of symptom severity, and treatment usually occurs when depression is moderate or severe. However, our research suggests that it might be in the patient's best interest to intervene early, at a time when symptoms are milder and perhaps more manageable, so that more severe depression and disability can be prevented. This requires broad-based tactics for depression screening with measures that are sensitive enough to capture even a few depressive symptoms.

It is noteworthy that many of the studies discussed above found no relationship between depression and severity of vision loss, suggesting that even patients with mild to moderate vision loss are at risk for depression and subsequent functional impairment. To test the hypothesis that depression is unrelated to the degree of visual impairment, we assessed visual acuity in 32 elderly psychiatric inpatients with major depression. Acuity was assessed at both admission and discharge. Acuity did not change as depression improved, and it was not related to depressive symp toms at either point.¹⁸ These results illustrate not only that visual acuity mea sures are unaffected by depression but also that degree of vision loss is unrelated to depression.

Depression can also affect the way in which ophthalmologists treat elderly patients with impaired vision. In an unpublished study, we interviewed 100 ophthalmologists to determine their level of awareness of depression in their patients and how it affects their care. While most (96%) recognized that de pression interferes with patients' functioning, two thirds stated that they do not pursue aggressive treatment in patients with depression, and 28% said that they do not refer patients who are depressed for rehabilitation. Considering the high rate of depression in these patients, as many as one third may not be offered important treatment interventions. This is especially disturbing because rehabilitation, in particular, may have an antidepressant effect.

In a group of older people newly referred for low vision rehabilitation, active participation in rehabilitation was related to a decrease in depressive symptoms over a 2-year period.¹⁹ Unlike other diseases of aging that cause depression (stroke, heart disease), the relationship between depression and vision loss is not physiologic in nature. Instead it is probably caused by loss of independence, the relinquishment of valued activities, and a decrease in social activities. Depression can erode feelings of self-efficacy, leaving people with the belief that they cannot accomplish anything. Rehabilitation presents an optimal opportunity to address all these issues and subsequently alleviate depression. Teaching techniques to complete tasks in novel ways may re store feelings of independence and control. In addition, allowing patients to realize that they can still participate in social events and other enjoyable activities is vital to helping them overcome depression.

As awareness of the psychological consequences of vision loss increases, more resources are being devoted to helping patients effectively live with this disability. In a randomized trial, Brody and colleagues²⁰ evaluated a group-level program to improve mood and function in 231 patients with AMD. Their 6-week intervention was led by a health professional and consisted of didactic instruction regarding basic information about AMD and rehabilitative strategies. It also contained a behavioral component that emphasized dealing with some of the challenges presented by AMD. Their data showed that the intervention group evinced a significant improvement in mood 6 weeks after baseline and that this effect was most pronounced for those who met criteria for depression at baseline. Subjects in the intervention group displayed improved function, and again, this effect was most apparent for those with depression. This study clearly demonstrates that both the emotional distress and functional declines that frequently accompany AMD can be improved.

In an attempt to prevent depression and its associated disabling effects, we received a grant from the National Institute of Mental Health to conduct a randomized controlled clinical trial to test the efficacy of a brief cognitive-behavioral therapy-Problem Solving Treatment (PST)-to prevent depression in 230 patients with new-onset bilateral AMD. This study is based on the premise that inaccurate appraisals of problems and dysfunctional problem-solving skills contribute to the on set of depression. It further posits that teaching patients effective problem-solving skills can foster independence, preserve function, and alleviate depressive symptoms.

Patients were randomized to PST or usual care and were monitored for 12 months (2, 6, and 12 months postbaseline). The main outcome was de pression status. Secondary outcomes included vision function (assessed by both self-report and observation) and general function. At this time, the 2-month data are available for analysis, and so far the results are promising. About 12% of the PST group became depressed at 2 months compared with 23% of the usual-care group. There was a parallel group difference in function; 23% of subjects in the PST group relinquished an important activity versus 37% in the usual-care group. These preliminary results indicate that the negative effects of vision loss can potentially be mitigated by improving patients' problem-solving skills.

Implications for practice
The research presented in this review has important implications for the way in which psychiatrists provide care to older patients with vision impairment. A focus on the affective and practical impact of the loss of valued activities may uncover important depressive symptoms and lead to an understanding of how depression can impair daily functioning. Acute changes in vision should prompt an ophthalmologic evaluation. Psychiatrists should also be aware that visually impaired older persons are at risk for visual hallucinations, ie, Charles Bonnet syndrome, and they should routinely query patients about visual misperceptions and hallucinations.²¹

An awareness of available services (low vision rehabilitation, support groups, mobility training) for the visually impaired and a willingness to en courage patients to pursue them might substantially improve mood and a sense of competence in these patients. Psychoeducational techniques that facilitate the development of effective problem-solving skills, particularly as they pertain to finding novel methods for completing everyday activities, appear to be helpful. If clinically im portant depressive symptoms persist despite these interventions, antidepressant medications may be helpful as well.²² Finally, psychiatrists can increase ophthalmologists' awareness of the importance and adverse effects of depression and collaborate with them to provide optimal care.

Conclusion
Clearly, the effects of vision loss extend well beyond objective visual limitations and involve many aspects of psycho social functioning, particularly mood. Depression commonly accompanies vision loss and is a major contributor to disability. Along these lines, future research should focus on training ophthalmologists to efficiently screen for depressive symptoms and appropriately refer patients with AMD who are depressed for treatment. In addition, new ways, such as the ones described in this article, need to be found to incorporate interventions into routine ophthalmologic care.

Dr Casten is assistant professor in the department of psychiatry and human behavior and Dr Rovner is professor in the departments of psychiatry and human behavior and neurology at Thomas Jefferson University in Philadelphia. They report that they have no conflicts of interest concerning the subject matter of this article.

References:

References1. Congdon N, O’Colmain B, Klaver CC, et al; Eye Diseases Prevalence Research Group. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122:477-485.
2. Klein R, Klein BE, Jensen SC, Meuer SM. The five-year incidence and progression of age-related maculopathy: the Beaver Dam Eye Study. Ophthalmology. 1997;104:7-21.
3. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthal mol. 2001;119:1417-1436.
4. Williams RA, Brody BL, Thomas RG, et al. The psycho social impact of macular degeneration. Arch Ophthalmol. 1998;116:514-520.
5. Alliance for Aging Research. Independence for older Americans: An Investment in Our Nation's Future. Available at: http://www.agingresearch.org/brochures/independence/welcome.html. Accessed October 5, 2006.
6. Crews JE, Campbell VA. Vision impairment and hearing loss among community-dwelling older Americans: implications for health and functioning. Am J Public Health. 2004;94:823-829.
7. Rovner BW, Casten RJ, Tasman WS. Effect of depression on vision function in age-related macular degeneration. Arch Ophthalmol. 2002;120:1041-1044.
8. Brody BL, Gamst AC, Williams RA, et al. Depression, visual acuity, comorbidity, and disability associated with age-related macular degeneration. Ophthalmology. 2001;108:1893-1900.
9. Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003;58:249-265.
10. Lebowitz BD, Pearson JL, Schneider LS, et al. Diag nosis and treatment of depression in late life. Consensus statement update. JAMA. 1997;278:1186-1190.
11. Yates WR. Epidemiology of psychiatric disorders in the medically ill. In: Robinson RG, Yates WR, eds. Psy chiatric Treatment of the Medically Ill. New York: Dekker; 1999:41-64.
12. Robinson RG, Starr LB, Kubos KL, Price TR. A two-year longitudinal study of post-stroke mood disorders: findings during the initial evaluation. Stroke. 1983;14:736-744.
13. Rovner BW, Casten RJ. Neuroticism predicts de pression and disability in age-related macular degeneration. J Am Geriatr Soc. 2001;49:1097-1100.
14. Rovner BW, Ganguli M. Depression and disability associated with impaired vision: the MoVies Project. J Am Geriatr Soc. 1998;46:617-619.
15. Rovner BW, Casten RJ. Activity loss and depression in age-related macular degeneration. Am J Geriatr Psy chiatry. 2002;10:305-310.
16. Horowitz A, Reinhardt JP, Kennedy GJ. Major and subthreshold depression among older adults seeking vision rehabilitation services. Am J Geriatr Psychiatry. 2005;13:180-187.
17. Rovner BW, Casten RJ, Hegel MT, Tasman WS. Minimal depression and vision function in age-related macular degeneration. Ophthalmology. 2006;113:1743-1747.
18. Rovner BW, Casten R. Stability of visual acuity mea surement in depression. Am J Geriatr Psychiatry. 2005;13:255-258.
19. Horowitz A, Reinhardt JP, Boerner K. The effect of rehabilitation on depression among visually disabled older adults. Aging Ment Health. 2005;9:563-570.
20. Brody BL, Roch-Levecq AC, Gamst AC, et al. Self-management of age-related macular degeneration and quality of life: a randomized controlled trial. Arch Op hthalmol. 2002;120:1477-1483.
21. Rovner BW. The Charles Bonnet syndrome: a review of recent research. Curr Opin Ophthalmol. 2006;17:275-277.
22. Rovner BW, Pasternak R, Casten R. A pilot study of sertraline for depression in age-related macular degeneration. Am J Geriatr Psychiatry. 2006;14:718-719.