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HomemistoryLost in the System: Eye Care to the Elderly

Lost in the System: Eye Care to the Elderly

Almost 200,000 Australians live in residential aged care facilities.1 Having contributed to the country’s economy and led active, social lives, many find their world shrinking around them as they grapple with poor vision, debilitating eye disease and other co-morbidities. Yet our first-world health system has challenges providing these people with the eye health services they need to maximise their vision and maintain quality of life. What can be done?

Attending medical appointments can be costly and burdensome at the best of times. Elderly people – particularly if they are frail or have dementia – often rely on their working children to take them to appointments. The need to maintain regular eye health checks can take a backseat to managing seemingly more pressing medical needs.

Once in a residential aged care facility appointments can become even more difficult to manage, particularly if family members live far away. As a result, treatment compliance may be jeopardised and refreshing medication supplies can be a challenge. Understandably, a person’s vision can slip away unnoticed.

A study currently being undertaken by Macular Disease Foundation Australia with funding from the federal Department of Health is investigating the eye health of people living in residential aged care facilities (RACFs) as well as the facilities’ policies and procedures regarding the management of eye conditions. Older research has indicated that, on average, residents of RACFs have worse vision than their equivalent aged peers. Yet despite this, they typically don’t receive the same support and services their peers receive to manage their vision or eye disease.

on average, residents of RACFs have worse vision than their equivalent aged peers

The Foundation hopes that once fully analysed, the study results will paint a clear picture of the current standard of eye care provided and inform on a model of care that is achievable within the day-to-day pressures of managing aged care facilities.

Numbers are Not Surprising

Retired ophthalmologist Dr. Jim Runciman is on the expert panel assisting the Foundation’s study. He says many people enter aged care because they have poor vision, which could account for the disproportionate number of vision impaired residents of RACFs versus the broader community.

“When people in the community have poor vision, they can become much more dependent on others for their day-to-day activities such as cleaning, cooking, paying bills and shopping,” said Dr. Runciman.

“Many with significant vision impairment may not have a supporting companion who can provide necessary assistance, so it is not surprising that they enter aged care facilities on an average of three years earlier than fully sighted people.”

Additionally, he pointed out that because all leading causes of vision impairment and blindness increase in frequency and severity with age (eg. age-related macular degeneration, cataract, diabetic retinopathy and glaucoma), it stands to reason that affected people are more likely to be living in aged care facilities.

“There is evidence from a number of older studies that people in aged care facilities do not receive comprehensive eye tests to detect and treat these conditions nor adequate follow-up care as often as they should.

“There can be many reasons for this, and the Foundation’s study aims to evaluate the current practice and the barriers to prevention, early detection, timely treatment and rehabilitation,” said Dr. Runciman.

Time to Act

Sydney optometrist Peter Hewett is another member of the expert panel that is assisting the study. He said faced with a rapidly growing ageing population, the study was timely.

“It’s great that the Foundation is looking at this area now because we really need to find a solution. Behind the scenes no one is noticing what’s going on every day – the elderly get lost in the system and they’re trying to cope on a day-to-day basis.”

He said the ageing eye is a “huge problem” for the eye health profession. “We are dealing with it more and more because the number of people living in RACFs is increasing fairly rapidly.

“It’s difficult for these residents – they’ve lost their independence and their vision which is one of the major ways they’ve always communicated with the world – the news and books they read, the programs they watch on television, and the family photos they look at and share. That’s their life so if they can’t see, their world becomes so much smaller and more isolated.”

Dr. Runciman agrees, “Maintaining functional vision helps to increase independence and safety. Without functional vision, a person becomes increasingly dependent on others, and is more likely to experience social withdrawal, depression, higher falls risk, and many other life challenges.

“People in RACFs often experience decreasing physical and mental capacity resulting in a major constriction of their daily world. Daily sensory input now becomes even more critical for maintaining their quality of life. They often have co-morbidities, particularly hearing loss. This, combined with poor vision, has a profoundly negative effect on their quality of life.”

Mr. Hewett said dementia is another complicating factor. “They may not notice a change in their vision or they may be unable to communicate a change they’ve noticed, and if they don’t say anything, then nothing will be done. In the case of dementia, vision loss further complicates life and can be very frustrating. Interestingly this can lead to the dementia worsening. It’s a complex problem.”

The Challenges of Providing Service

Mr. Hewett said people in RACFS are not getting the regular review and management they need, yet often they are the ones who are most susceptible to eye disease because of their age and poor health.

He said delivering eye care to RACFs is frustrating because it is impossible to offer the highest level of care provided in a consulting room. “In our practice we are often called by a relative or a facility to come and see a resident – usually someone who used to come to us as a patient. Often when we get to the facility we find there isn’t an ideal space to conduct an eye test – the length of the room is inappropriate and lighting is not adequate, for example. We are also limited by the amount of equipment we can take in because while we have some portable equipment, a lot of it can’t be moved easily. Logistically, it’s impossible to take a great range of spectacles so the residents’ choices are limited.”

“The trouble with the way we do look after their eye care is that we don’t do it on a systematic basis. The majority would need to have an OCT at a minimum, and most would need their visual fields tested. That’s not something we can do on a one-off visit to the RACF.”

The Challenge of Remuneration

Appropriate remuneration is another challenge for optometrists who are called out to RACFs. Time taken to prepare for off-site appointments, travel to the destination and undertake a consultation, particularly if a patient has dementia or is frail, is extensive and in no way covered by Medicare.

In rural Australia the challenge of providing eye care to residential aged care facilities is further compounded by the tyranny of distance and a lower ratio of optometrists to patients. Gunnedah optometrist Tim Duffy, who was recently recognised with the Lederer Award, says, “delivering eye care to RACFs is a service done out of the kindness of your heart… We perform a lot of clinics in regional areas so we have invested in portable equipment, which makes a difference. But delivering eye care to residential aged care facilities takes time and the financial remuneration doesn’t cover it – in fact there’s an opportunity cost to not being in the practice.

“In optometry, most financial remuneration comes from spectacle sales but in residential aged care many patients are beyond spectacles due to conditions like age-related macular degeneration so there are few sales to be made. We refer patients on to low vision agencies if appropriate but often the cost of low vision technologies can be a barrier and unfortunately, Vision Australia in Tamworth recently closed which in our region has reduced services available to patients.” **

Expanding Co-Management

Although optometrists and ophthalmologists typically work very well together in the care of their shared patients, effective co-management within a residential aged care facility requires more extensive and systematic communication.

“When we go out to see someone in a facility we need to keep everyone in the loop – GPs, family, the ophthalmologist and the facility,” said Mr. Hewett. “This is a big issue. I think many facilities have systems in place to ensure notes are kept on-site and that people can see what is being done, but when you get various practitioners coming in, there can be confusion about who to report to and how – so there needs to be guidelines in place to facilitate the process.”

Julie Heraghty, Chief Executive Officer of Macular Disease Foundation Australia, says this is something the Foundation intends to work on once the study has been completed. “Across the eight RACFs in our study we found that recording procedures varied from facility to facility. It is important to get some consistency. Working with our advisory group, and using the insights from our study, we will develop protocols and procedures to facilitate an understanding among RACF staff members so that issues with vision and eye disease are identified and well managed. We realise of course that RACFs are already stretched and that their workload is increasing, so we are trying to develop recommended procedures and protocols with this in mind.” She said the Foundation would also produce literature for RACF staff, residents and their families, aimed at increasing awareness of the importance of regular eye tests, screening and where necessary, treatment.

Dr. Runciman said education about eye conditions and diseases would help residents, their family members and RACF staff to recognise problems and understand the need for various courses of action.

“It is possible that not only aged care residents themselves, but also their families and aged care staff may have preconceptions that vision loss is inevitable, and are unaware of the importance of management of eye health. Older people can be very stoic and often don’t wish to make a fuss about their vision, so changes in vision may not be communicated to staff by residents,” he said. “Solutions to vision impairment may be as simple (but life altering) as an eye check and new glasses, or even checking the person is actually wearing their glasses, through to modern cataract implant surgery or injections for wet age-related macular degeneration.”

Mr. Hewett agrees that education is particularly important. “Staff at residential aged care facilities will typically go out of their way to help patients if they understand the problem and importance of delivering the solution. I had a patient with an eye condition that meant he could only wear rigid contact lenses, which are expensive. He also had Parkinson’s disease, which was making it difficult for him to insert and remove his lenses. He kept losing them so I went to the facility to train the staff on how to do this for him. One of the staff members told me he should be wearing glasses – a simple solution in her mind. I had to explain that he wasn’t wearing the lenses for reasons of vanity and that if he could wear glasses he would. Once the staff were aware of that they were so keen to learn. I taught them how to handle his contact lenses and they were happy to help my patient.”

Mr. Hewett said another “huge problem” within RACFs is maintenance of eye wear. “Glasses get broken in the mechanisms of beds or they get lost, the lenses get dirty and scratched and the problem may go unnoticed because the resident doesn’t speak up. And then there are many people whose vision is so poor – a large proportion of elderly people have macular degeneration for instance – that they could really do with low vision aids and technologies.

Maximised Vision is a Human Right

The landscape of eye health has changed dramatically in the last 10 years with new treatments relying on early detection and timely treatment. Additionally, the availability of new low vision aids and technologies can now greatly enhance quality of life, enabling many people to not only regain more independence but also regain the ability to read a book, watch TV, see photos of their grandchildren or hear the daily news read from a device.

Dr. Runciman believes that if the Foundation’s study finds that treatments or low vision supports are less accessible in aged care than they are in the broader community, this would clearly be an area for improvement.

“For many in aged care, music, reading, television and seeing their family and grandchildren are the joys of life, contributing to physical and mental health,” he said.

According to the Accreditation Standards for Quality of Care Principles, providers of residential aged care have responsibilities to provide care and services to meet care recipient needs. This includes “Personal assistance, including individual attention, individual supervision, and physical assistance, with… communication, including to address difficulties arising from impaired hearing, sight or speech, or lack of common language (including fitting sensory communication aids), and checking hearing aid batteries and cleaning spectacles”.2

With this in mind, Tim Connell from Quantum RLV believes facilities that do not recommend low vision aids to residents who could benefit from them, may be unwittingly breaching their duty of care.

“We constantly give talks in residential care facilities – and when we ask who knows what a hearing aids is, everyone puts their hands up. When we ask them whether they know what a vision aid is we’ll usually find that only one or two people put their hands up.

“So there’s an overwhelming lack of awareness of what vision aids are – why they’re important for someone with low vision. I think this is probably because most facilities have a long history of providing care, so they’ve got a care focus rather than a reablement focus. This is despite all the new government programs for aged care being aimed at reablement – about putting services in place to enable people to maximise their independence. Regaining independence returns quality of life and it reduces costs to the aged care facility, yet the facilities are finding it hard to get their heads around this.”

Mr. Connell said when it comes to achieving reablement, low vision aids are enormously successful. “With the right piece of technology, people with low vision are able to do a whole range of things they couldn’t do before.”

He said, among those who are aware of low vision aids and technologies, a significant impediment to investment is cost. “Some facilities have installed desktop magnifiers and reading machines in common rooms, and they view this as a competitive advantage when it comes to attracting new residents. However many have an inbuilt resistance because they see low vision equipment as a high cost that they can’t directly get back from their residents.

“We often find it’s individuals who invest in technologies, then once other staff members, other residents or family members see the equipment in action, they see the value of the equipment and they change their minds.”

Mr. Connell cited the example of a client in Taree who told him the low vision equipment Quantum RLV had provided had changed her life. “She was overwhelmed. Her family and staff immediately noticed the difference it made to her quality of life as well.”

He said under the My Aged Care program, implemented in February 2017, he expects individuals will invest more in low vision aids and equipment. “Funding now goes with the client so all agencies are suddenly working more proactively, they’re competing for the services of the client – so I’m a little bit hopeful that we’ll start to see change as they look for new ways to enhance each client’s quality of life.”

As with delivering eye screening services, there are logistical challenges to be overcome when supplying low vision aids and technologies to residential aged care facilities. Small rooms require well designed equipment that can be attached to a wall and pulled out or used on a chair table.

Cognitive impairment demands that technologies are robust and simple to use as staff often don’t have time to assist on a daily basis. “We always take equipment in with us for the residents to try. Before we go, we have a discussion with the person, their carer or a family member to ascertain their needs and their capability. People mostly fear the device will be overly complicated, so we’ll start them with something simple that will get them engaged, then we’ll move them up to equipment that’s more suited. The aim is to ensure the resident has equipment they can manage and that enhances their quality of life. If it’s a product they can’t use and that takes the time of staff, we’d typically withdraw it, but it’s rare that we need to do so because we’ve worked to qualify the person beforehand.”

What’s the Solution?

When Macular Disease Foundation Australia releases its full report on the delivery of eye health into Australia’s residential aged care facilities it will, no doubt, contain a firm direction for the future.

The successful model will need to take into account the specific screening needs of different patients in terms of equipment required and screening intervals for various conditions such as diabetic eye disease. It will also need to account for distances between RACFs and the time it takes to consult to patients, particularly those who are frail and have dementia.

Regardless of the solution eventually settled on, one thing is certain: with an ageing population, the delivery of eye care is a role that will continue to expand. In 2016, 15 per cent of Australia’s population (3.7 million) was aged 65 and over. By 2056 we can expect that proportion to be 22 per cent (8.7 million) and by 2096, it will be 24 per cent (12.8 million).3 That’s a long way off but it’s a problem that needs to be resolved now because it’s not reasonable to assume optometrists will continue to provide eye care to RACFs from the kindness of their hearts. Tim Duffy says, “to rely on the good will of people to solve a major problem is not sustainable in the long term. You need to have a system in place that ensures the best people able to provide the service are those who are employed to do it”.

1. www.aihw.gov.au/aged-care/residential-and-home-care-2014-15/services-and-places
2. legislation.gov.au/Details/F2014L00830
3. aihw.gov.au/ageing/older-australia-at-a-glance/

** Vision Australia still has a permanent presence in the Tamworth and wider New England region. A Vision Australia occupational therapist is based in the region and other staff including Orientation & Mobility Specialists, Orthoptists and Assistive Technology Specialists visit the region every six – eight weeks to provide services to new and existing clients. When in the region Vision Australis staff work with clients in their own home or in community facilities. Vision Australia encourages anybody in the New England region concerned about vision loss to make contact immediately. 1300 84 74 66.