Intervention can benefit some nursing home residents

Baltimore?A trial program that provided support and advice to older nursing home residents with poor vision improved their access to cataract surgery substantially. But the debilitated condition of many of those residents led to hesitation about surgery not only from physicians looking after the older people but also from their guardians, according to ophthalmologists at the Johns Hopkins University's Wilmer Eye Institute, Baltimore.

The program was initiated since there is uncertainty about how to treat cognitively impaired persons with vision loss.

To see if the situation could be improved, Dr. Friedman and colleagues initiated the Salisbury Eye Evaluation in Nursing Home Groups (SEEING) trial in 28 nursing homes on the eastern shores of Maryland and Dela-ware, all within a 2-hour drive from Salisbury, MD. The homes were divided into two groups, matched by size (number of beds) and a proportion of self-paying patients.

Nursing home occupants were eligible for the study if they were 65 or older, were not in hospice care or at immediate risk of death, and were not short-stay individuals. In all, 1,305 residents were included.

All the occupants underwent visual acuity screening; those with visual impairment had full ophthalmologic exams. The results were reported to the nursing home occupants, their physicians, and their guardians, with the decision on intervention, if necessary, left to the discretion of the family.

Half the homes were assigned to a usual-care group, with nothing further done. The other 14 homes were included in an intervention group. In these homes, if the exams indicated the need for new eyeglasses, low-vision care, or cataract surgery, members of the SEEING project staff facilitated access to those services within the nursing home.

Cataract surgery was recommended for residents with visual acuity worse than 20/40 owing to cataract or posterior capsular opacification, as determined by the study ophthalmologist after a detailed exam. In all, 496 individuals were found to have visual impairment, with cataract identified as the primary cause in 177 of them: 78 in the intervention homes, 99 in the control homes.

In the intervention homes, the study provided assistance in obtaining services. A project coordinator provided the family with a video on cataract, called the family to follow up, and notified the nursing homes and guardians of the need for surgery. The project provided transportation to and from the surgical facility for a preoperative visit, the surgery itself, and one postoperative visit. The project director worked with the nursing home staff, family, and patients to schedule the surgery. Guardians and the nursing home staff were notified of the cause of decreased vision in the control homes and nothing further was done.

The results were strikingly different. In the intervention homes, 31% of the residents for whom cataract surgery was recommended had the procedure performed, compared with 2% in the control homes, results that Dr. Friedman called "pretty amazing." Even in the intervention homes, the result was lower than could be hoped for, for a variety of reasons.