Associations of Self-reported Vision Impairment With Anxiety and Depression Among Older Adults | Anxiety Disorders | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Longitudinal Associations of Self-reported Vision Impairment With Symptoms of Anxiety and Depression Among Older Adults in the United States

Educational Objective
To evaluate the longitudinal association and directionality of the association between self-reported visual impairment (VI) and clinically significant symptoms of depression and anxiety in older US adults.
1 Credit CME
Key Points

Question  What is the longitudinal association between self-reported vision impairment and depression and anxiety symptoms in older US adults?

Findings  In this 5-year, nationally representative cohort study of 7584 Medicare beneficiaries 65 years and older, participants with self-reported vision impairment at baseline had an increased hazard of reporting future symptoms of depression, and those with depression or anxiety symptoms at baseline had an increased hazard of reporting vision impairment in the future.

Meaning  The findings suggest a longitudinal and bidirectional association between vision impairment and mental health symptoms in older US adults.

Abstract

Importance  Vision impairment (VI) and mental health conditions are highly prevalent among older adults and are major causes of morbidity and health care expenditures. However, there are few nationally representative data from the United States on the longitudinal association between VI and depressive symptoms, and no such data on anxiety symptoms.

Objective  To evaluate the longitudinal association and directionality of the association between self-reported VI and clinically significant symptoms of depression and anxiety in older US adults.

Design, Setting, and Participants  The National Health and Aging Trends Study, a nationally representative US survey administered annually from 2011 to 2016 to a cohort of Medicare beneficiaries 65 years and older. A total of 7584 participants with complete data on self-reported VI status at baseline were included. Data analysis was performed from February to October 2018.

Main Outcomes and Measures  Multivariable Cox proportional hazards regression models were used to evaluate the longitudinal associations between self-reported VI and depression and anxiety symptoms, adjusting for sociodemographics and medical comorbidities and accounting for the complex survey design.

Results  There were 7584 participants included in this study. At baseline, the survey-weighted proportion of participants who were women was 56.6%; 53.0% were aged 65 to 74 years, and 8.9% (95% CI, 8.1%-9.8%) had self-reported VI. Symptoms of depression were significantly more common in participants with self-reported VI than those without self-reported VI (31.2%; 95% CI, 27.0%-35.6% vs 12.9%; 95% CI, 11.9%-14.0%; P < .001), as were symptoms of anxiety (27.2%; 95% CI, 23.7%-30.9% vs 11.1%; 95% CI,10.2%-12.0%, P < .001). Baseline self-reported vision status was significantly associated with future report of depression (hazard ratio [HR], 1.33; 95% CI, 1.15-1.55) but not anxiety (HR, 1.06; 95% CI, 0.85-1.31) symptoms. Baseline depression (HR, 1.37; 95% CI, 1.08-1.75) and anxiety (HR, 1.55; 95% CI, 1.19-2.02) symptoms were both significantly associated with future reports of self-reported VI. In a sensitivity analysis excluding data provided by proxy respondents, statistical significance was unchanged and the effect size was similar for all statistical models.

Conclusions and Relevance  Older US adults with self-reported VI were more likely to report symptoms of depression in the future, while those who had symptoms of either depression or anxiety were more likely to report VI in the future. This investigation suggests that there is a significant bidirectional and longitudinal association between self-reported VI and mental health symptoms. Furthermore, the study suggests the need for effective strategies to screen for and address depression and anxiety among older US adults with VI.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Accepted for Publication: March 5, 2019.

Corresponding Author: Joshua R. Ehrlich, MD, MPH, Center for Eye Policy and Innovation, Department of Ophthalmology and Visual Sciences, University of Michigan, 1000 Wall St, Ann Arbor, MI 48105 (joshre@med.umich.edu).

Published Online: May 16, 2019. doi:10.1001/jamaophthalmol.2019.1085

Author Contributions: Dr Ehrlich had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Frank, Stagg, Ehrlich.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Frank, Xiang, Ehrlich.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Frank, Xiang, Ehrlich.

Obtained funding: Ehrlich.

Supervision: Stagg, Ehrlich.

Conflict of Interest Disclosures: Dr Ehrlich reported grants from National Institutes of Health, grants from Lighthouse Guild, and grants from Research to Prevent Blindness during the conduct of the study. No other disclosures were reported.

Funding/Support: This research was supported by grant K23 EY027848 from the National Eye Institute (Dr Ehrlich), a grant from Lighthouse Guild to the Department of Ophthalmology and Visual Sciences at the University of Michigan, and an unrestricted grant from Research to Prevent Blindness to the Department of Ophthalmology and Visual Sciences at the University of Michigan.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Bourne  RRA, Flaxman  SR, Braithwaite  T,  et al; Vision Loss Expert Group.  Magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: a systematic review and meta-analysis.  Lancet Glob Health. 2017;5(9):e888-e897. doi:10.1016/S2214-109X(17)30293-0PubMedGoogle Scholar
2.
World Health Organization. Mental health of older adults—fact sheet. World Health Organization Media Centre. http://www.who.int/mediacentre/factsheets/fs381/en/. Published December 12, 2017. Accessed October 1, 2018.
3.
Wahl  H-W.  The psychological challenge of late-life vision impairment: concepts, findings, and practical implications.  J Ophthalmol. 2013;2013:278135. doi:10.1155/2013/278135PubMedGoogle Scholar
4.
Vos  T, Abajobir  AA, Abate  KH,  et al; GBD 2016 Disease and Injury Incidence and Prevalence Collaborators.  Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.  Lancet. 2017;390(10100):1211-1259. doi:10.1016/S0140-6736(17)32154-2PubMedGoogle Scholar
5.
Zhang  X, Bullard  KM, Cotch  MF,  et al.  Association between depression and functional vision loss in persons 20 years of age or older in the United States, NHANES 2005-2008.  JAMA Ophthalmol. 2013;131(5):573-581. doi:10.1001/jamaophthalmol.2013.2597PubMedGoogle Scholar
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(5):823-829. doi:10.2105/AJPH.94.5.823PubMedGoogle Scholar
7.
Crews  JE, Chou  C-F, 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.2017.06.038PubMedGoogle Scholar
8.
Simning  A, Fox  ML, Barnett  SL, Sorensen  S, Conwell  Y.  Depressive and anxiety symptoms in older adults with auditory, vision, and dual sensory impairment [published online June 1, 2018].  J Aging Health. doi:10.1177/0898264318781123PubMedGoogle Scholar
9.
Zheng  DD, Bokman  CL, Lam  BL,  et al.  Longitudinal relationships between visual acuity and severe depressive symptoms in older adults: the Salisbury Eye Evaluation study.  Aging Ment Health. 2016;20(3):295-302. doi:10.1080/13607863.2015.1008985PubMedGoogle Scholar
10.
Bernabei  V, Morini  V, Moretti  F,  et al.  Vision and hearing impairments are associated with depressive—anxiety syndrome in Italian elderly.  Aging Ment Health. 2011;15(4):467-474. doi:10.1080/13607863.2011.562483PubMedGoogle Scholar
11.
Hong  T, Mitchell  P, Burlutsky  G, Gopinath  B, Liew  G, Wang  JJ.  Visual impairment and depressive symptoms in an older Australian cohort: longitudinal findings from the Blue Mountains Eye Study.  Br J Ophthalmol. 2015;99(8):1017-1021. doi:10.1136/bjophthalmol-2014-306308PubMedGoogle Scholar
12.
Han  JH, Lee  HJ, Jung  J, Park  EC.  Effects of self-reported hearing or vision impairment on depressive symptoms: a population-based longitudinal study  [published online February 8, 2018].  Epidemiol Psychiatr Sci. PubMedGoogle Scholar
13.
Carrière  I, Delcourt  C, Daien  V,  et al.  A prospective study of the bi-directional association between vision loss and depression in the elderly.  J Affect Disord. 2013;151(1):164-170. doi:10.1016/j.jad.2013.05.071PubMedGoogle Scholar
14.
Heesterbeek  TJ, van der Aa  HPA, van Rens  GHMB, Twisk  JWR, van Nispen  RMA.  The incidence and predictors of depressive and anxiety symptoms in older adults with vision impairment: a longitudinal prospective cohort study.  Ophthalmic Physiol Opt. 2017;37(4):385-398. doi:10.1111/opo.12388PubMedGoogle Scholar
15.
Chou  KL.  Combined effect of vision and hearing impairment on depression in older adults: evidence from the English Longitudinal Study of Ageing.  J Affect Disord. 2008;106(1-2):191-196. doi:10.1016/j.jad.2007.05.028PubMedGoogle Scholar
16.
Sloan  FA, Ostermann  J, Brown  DS, Lee  PP.  Effects of changes in self-reported vision on cognitive, affective, and functional status and living arrangements among the elderly.  Am J Ophthalmol. 2005;140(4):618-627. doi:10.1016/j.ajo.2005.01.019PubMedGoogle Scholar
17.
Löwe  B, Kroenke  K, Gräfe  K.  Detecting and monitoring depression with a two-item questionnaire (PHQ-2).  J Psychosom Res. 2005;58(2):163-171. doi:10.1016/j.jpsychores.2004.09.006PubMedGoogle Scholar
18.
Kroenke  K, Spitzer  RL, Williams  JBW, Löwe  B.  An ultra-brief screening scale for anxiety and depression: the PHQ-4.  Psychosomatics. 2009;50(6):613-621. doi:10.1176/appi.psy.50.6.613PubMedGoogle Scholar
19.
Cosh  S, von Hanno  T, Helmer  C,  et al.  The association amongst visual, hearing, and dual sensory loss with depression and anxiety over 6 years: The Tromsø Study.  Int J Geriatr Psychiatry. 2018;33(4):598-605. doi:10.1002/gps.4827PubMedGoogle Scholar
20.
Kempen  GIJM, Zijlstra  GAR.  Clinically relevant symptoms of anxiety and depression in low-vision community-living older adults.  Am J Geriatr Psychiatry. 2014;22(3):309-313. doi:10.1016/j.jagp.2012.08.007PubMedGoogle Scholar
21.
van der Aa  HPA, Comijs  HC, Penninx  BWJH, van Rens  GHMB, van Nispen  RMA.  Major depressive and anxiety disorders in visually impaired older adults.  Invest Ophthalmol Vis Sci. 2015;56(2):849-854. doi:10.1167/iovs.14-15848PubMedGoogle Scholar
22.
Cosh  S, Naël  V, Carrière  I,  et al; The Sense-Cog Consortium.  Bidirectional associations of vision and hearing loss with anxiety: prospective findings from the Three-City Study [published online May 3, 2018].  Age Ageing. doi:10.1093/ageing/afy062PubMedGoogle Scholar
23.
National Health & Aging Trends Study. https://www.nhats.org/. Accessed November 1, 2018.
24.
Kroenke  K, Spitzer  RL, Williams  JBW, Löwe  B.  The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review.  Gen Hosp Psychiatry. 2010;32(4):345-359. doi:10.1016/j.genhosppsych.2010.03.006PubMedGoogle Scholar
25.
Plummer  F, Manea  L, Trepel  D, McMillan  D.  Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis.  Gen Hosp Psychiatry. 2016;39:24-31. doi:10.1016/j.genhosppsych.2015.11.005PubMedGoogle Scholar
26.
Kasper JD, Freedman VA, Spillman BC. Classification of persons by dementia status in the National Health and Aging Trends Study. https://www.nhats.org/scripts/documents/DementiaTechnicalPaperJuly_2_4_2013_10_23_15.pdf. Published July 2013. Accessed October 1, 2018.
27.
Kaplan  EL, Meier  P.  Nonparametric estimation from incomplete observations.  J Am Stat Assoc. 1958;53(282):457-481. doi:10.1080/01621459.1958.10501452Google Scholar
28.
Skolarus  LE, Sánchez  BN, Morgenstern  LB,  et al.  Validity of proxies and correction for proxy use when evaluating social determinants of health in stroke patients.  Stroke. 2010;41(3):510-515. doi:10.1161/STROKEAHA.109.571703PubMedGoogle Scholar
29.
Wolinsky  FD, Jones  MP, Wehby  GL.  Gathering data from older adults via proxy respondents: research challenges.  J Comp Eff Res. 2012;1(6):467-470. doi:10.2217/cer.12.54PubMedGoogle Scholar
30.
Heeringa  SG, West  BT, Berglund  PA.  Applied Survey Data Analysis. 2nd ed. Boca Raton, FL: Chapman and Hall/CRC; 2017, doi:10.1201/9781315153278
31.
Evans  JR, Fletcher  AE, Wormald  RPL.  Depression and anxiety in visually impaired older people.  Ophthalmology. 2007;114(2):283-288. doi:10.1016/j.ophtha.2006.10.006PubMedGoogle Scholar
32.
Yip  JLY, Khawaja  AP, Broadway  D,  et al.  Visual acuity, self-reported vision and falls in the EPIC-Norfolk Eye study.  Br J Ophthalmol. 2014;98(3):377-382. doi:10.1136/bjophthalmol-2013-304179PubMedGoogle Scholar
33.
Glynn  RJ, Rosner  B, Christen  WG.  Evaluation of risk factors for cataract types in a competing risks framework.  Ophthalmic Epidemiol. 2009;16(2):98-106. doi:10.1080/09286580902737532PubMedGoogle Scholar
34.
Rovner  BW, Casten  RJ, Hegel  MT,  et al.  Low vision depression prevention trial in age-related macular degeneration: a randomized clinical trial.  Ophthalmology. 2014;121(11):2204-2211. doi:10.1016/j.ophtha.2014.05.002PubMedGoogle Scholar
35.
National Academies of Sciences Engineering and Medicine.  Making Eye Health a Population Health Imperative. Washington, DC: National Academies Press; 2016. doi:10.17226/23471
36.
Otte  B, Woodward  MA, Ehrlich  JR, Stagg  BC.  Self-reported eyeglass use by US Medicare beneficiaries aged 65 years or older.  JAMA Ophthalmol. 2018;136(9):1047-1050. doi:10.1001/jamaophthalmol.2018.2524PubMedGoogle Scholar
37.
Lam  BL, Lee  DJ, Zheng  DD, Davila  EP, Christ  SL, Arheart  KL.  Disparity in prevalence of self-reported visual impairment in older adults among US race-ethnic subgroups.  Ophthalmic Epidemiol. 2009;16(3):144-150. doi:10.1080/09286580902863007PubMedGoogle Scholar
38.
Campbell  VA, Crews  JE, Moriarty  DG, Zack  MM, Blackman  DK.  Surveillance for sensory impairment, activity limitation, and health-related quality of life among older adults—United States, 1993-1997.  MMWR CDC Surveill Summ. 1999;48(8):131-156.PubMedGoogle Scholar
39.
Whillans  J, Nazroo  J.  Assessment of visual impairment: the relationship between self-reported vision and “gold-standard” measured visual acuity.  Br J Vis Impairment. 2014;32(3):236-248. doi:10.1177/0264619614543532Google Scholar
40.
Jampel  HD, Frick  KD, Janz  NK,  et al; CIGTS Study Group.  Depression and mood indicators in newly diagnosed glaucoma patients.  Am J Ophthalmol. 2007;144(2):238-244. doi:10.1016/j.ajo.2007.04.048PubMedGoogle Scholar
41.
Ehrlich  JR, Stagg  BC, Andrews  C, Kumagai  A, Musch  DC.  Vision impairment and receipt of eye care among older adults in low- and middle-income countries [published online November 21, 2018].  JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2018.5449PubMedGoogle Scholar
42.
Ehrlich  JR, Hassan  SE, Stagg  BC.  Prevalence of falls and fall-related outcomes in older adults with self-reported vision impairment.  J Am Geriatr Soc. 2019;67(2):239-245. doi:10.1111/jgs.15628PubMedGoogle Scholar
43.
Varma  R, Vajaranant  TS, Burkemper  B,  et al.  Visual impairment and blindness in adults in the United States: demographic and geographic variations from 2015 to 2050.  JAMA Ophthalmol. 2016;134(7):802-809. doi:10.1001/jamaophthalmol.2016.1284PubMedGoogle Scholar
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close