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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.


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.

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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 (

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.

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