healthy ageing for eye health

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Eye health for healthy ageing

Wendy Holmes, Burnet Institute, [email protected]

Enso, Peradeniya, Sri Lanka

and

Healthy ageing for eye health


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• 285 million with visual impairment, 39 million blind worldwide

• More than 82% of all blind people, and 65% of visually impaired, are over 50 years

• 80% of all visual impairment can be avoided or cured.

• Least developed regions have greatest burden of visual impairment

• Women have a higher risk of visual impairment Pascolini D, Mariotti SPM. Global estimates of visual impairment: 2010. British Journal Ophthalmology, December 1, 2011 10.1136/bjophthalmol-2011-300539

Poor sight is a significant issue


3333Albion estate Elders’ Club,Sri Lanka

Holmes W


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www.newdynamics.group.shef.ac.uk/

Spot the difference…

Elders’ group, Sheffield, UK


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Major causes of visual impairment globally:

• uncorrected refractive errors (myopia, hyperopia or astigmatism) (43 %)

• cataract, (33%)• glaucoma (2%)

Major causes of blindness:• cataract (39%) • uncorrected refractive errors (18%) • glaucoma (10%) • age-related macular degeneration (7%) • corneal opacity (4%) • diabetic retinopathy (4%) • trachoma (3%) • eye conditions in children (3%)• onchocerciasis (0.7%)


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As people age the normal structure and functions of the eye deteriorate affecting vision

Blinding disorders increase in frequency

www.hollows.org/


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Nirmalan PK et al. Br J Ophthalmol 2002;86:505–512

Cluster random sample, n = 5411 > 50 years

Bilateral blindness: 11.0%

About 66% due to cataract

About 25% due to refractiveerror

Eye survey of older adults in Tamil Nadu


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Eye health screening

PALM Foundation, with

support from HelpAge Sri

Lanka, conducted 5 eye

screening camps in Nuwara

Eliya district

Anyone over 60 years with any concerns about their sight invited to attend (43% attended)


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Eye health screening

1,139 people > 60 years screened

525 (46%) of those screened had cataracts

Estimated 20% of estate elders have cataracts, (if those who were not screened did not have cataracts)

In addition 13% already operated = ~ 33% prevalence


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Cataract• Defined as opacity in the lens

interfering with vision

• Most common age-related eye disease

• Most treatable cause of vision loss in older adults

• Nearly two thirds of the diabetics in the Tamil Nadu study had evidence of cataract (2008)

• Other risk factors:smoking; obesity; poor diet; lack of physical activity; poor cardio-respiratory fitness; genetic predisposition; UV light exposure

PALM Foundation


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Refractive error

Failure of the optical surfaces of the eye to focus images clearly on the retina resulting in a blurred image

• Myopia (short-sightedness) is especially common in Asia - tends to begin in youth

• Hypermetropia (long-sightedness) tends to begin as people get older

• Presbyopia – ability of the ageing eye to focus images on the retina decreases


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Burden of poor sight among older people increasing dramatically

• The populations of Asian countries are ageing rapidly - much more rapidly than in developed countries

• At the same time as globalization, migration, modern influences, urban living, smaller families, changes in traditional roles, and women working outside the home

• By 2020 it is predicted that 67% of the global population over 60 years will live in developing countries

Shrestha LB: Population ageing in developing countries. Health Affairs 2000, 19(3):204-212


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• Sri Lanka one of the fastest ageing countries

• 9.2% > 60 years old in 2001, predicted to rise to 28.5% in 2050 (WB 2008)

• 2005/6 national survey - one in five adults has either diabetes or pre-diabetes; one-third of those with diabetes are undiagnosed (Katulanda P, et al. 2008)

• 1998 study - in Sri Lanka, as in other Asian countries, diabetic control was generally poor, with 54% of the sample having HbA1c values over 8%(Chuang LM, et al. 2002)

Sri Lanka provides a useful example


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Poor vision is often accompanied by other disabilities - arthritis, paralysis, deafness, or frailty, or by illness, which inhibit mobility

The impact of poor vision is often greater in old age

www.ewenbell.com

http://www.ewenbell.com/


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Significant international response to poor vision and blindness in low and

middle income countries

• WHO has led the Vision 2020 Global Initiative since 1999 aiming to ‘eliminate avoidable blindness by the year 2020’

• Supported by a wide range of eye INGOs

• Addresses specific eye problems in a vertical manner: CataractChildhood blindness Diabetic retinopathy GlaucomaTrachomaRefractive errors


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Sri Lanka Ministry of Health has a:

• National Vision 2020 Secretariat

• National Steering Committee

• National Programme for Prevention and Control of Avoidable Blindness

• Five year National Plan 2007 – 2012

Urgent need to integrate prevention and care for vision problems with general PHC and

health promotion

Vision 2020 initiatives at national level


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Sri Lanka

National Action Plan on Ageing

SRI LANKA

2011 - 2015

Ministry of Social ServicesNational Council for Elders

There is often a split between responses to “NCDs” and to ageing


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WHO approach – illustrated in Sri Lanka MoH plan


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Diabetes prevalence in Australia and Sri Lanka (2009)

Age group Sri Lanka Australia30 - 39 ~7% ~1%40 – 49 ~12% ~3%50 – 59 ~17% ~8%60-69 ~20% ~12%


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High prevalence of hypertension

For example:

In a rural Central Indian population of ages 30+ years, the prevalence of arterial hypertension was 22.1 ± 0.6% with an awareness rate of 20% and a treatment rate of 8%.

Jost B. et al. American Journal of Hypertension 2010; 23 4, 347–350. doi:10.1038/ajh.2009.276


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Quality of life

Focusing on death as the outcome of concern may result in neglect of common conditions that affect quality of life

For example: visual impairment pain and restricted movement associated with arthritis depression, anxiety and dementia urinary incontinence sexual health problems falls violence or neglect - often hidden


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Population burden of disease National cross-sectional multistage random sampling survey in

Thailand in 1997 4,048 > 60 years interviewed 769 (19%) reported having a long-term disability Nearly half with disability suffered 2 or more health problems Population burden of disease:

hemiparesis; arthritis; accidents; blindness and other eye diseases; kyphosis; weakness of limbs; deafness; hypertension.

“This ranking of public health priority differs from conventional approaches using mortality statistics and disability adjusted life years (DALYs).”

Jitapunkul S, et al. Determining public health priorities for an ageing population: the value of a disability survey. Southeast Asian

J Trop Med Public Health. 2003 Dec;34(4):929-36.

http://www.ncbi.nlm.nih.gov/pubmed/15115112


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The health problems of ageing in low income settings are characterised by:

Chronicity

Co-morbidity

Preventable disability

Earlier health hazards

Barriers to health care

Potential for catastrophe

Increasing vulnerability

But also - resilience


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Barriers to health care for elders

Transport costs User fees Cost of drugs Lack of mobility Health care provider attitudes Long waiting times Fear of forms


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Implications for health services

We need:

Continuous rather than episodic care – older person primary manager of own health care

Home based elders’ health records Strong referral links to specialists and social welfare services Respite and palliative care Integration between health facilities and community – home

visits, links with CBOs and NGOs Integration across the life span – preparation for healthy ageing


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Implications for health services

Older people’s contact with health services often through grandchildren

Front line health care workers need training: in communication and counselling skills to assess older people: BP; pulse; teeth; visual acuity; peak

flow; “how are things at home?” to give simple health promotion advice – and how to help older

people to manage their medicines


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WHO have a useful toolkit on PHC for elders – and many other useful resources at their web-site


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Efforts to improve vision can contribute to the prevention and management of NCDs and other age-related health problems

• When older people are able to see clearly they have a better quality of life and can continue to take an active part in their families and communities

• Social participation protects against many ageing-related conditions, through both physiological and psychological mechanisms

Holt-Lunstad J, et al. Social relationships and mortality risk: A meta-analytic review. PLoS Med 2010, 7:e1000316.


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• Poor vision makes it difficult for elders to prevent and manage other health problems:

- limits physical exercise, increases risk of injuries, increases social isolation, difficult to travel to health care services, and to take medicines correctly

• Prospect of improved sight - motivating factor for older

people to attend health services, where they can then be screened and treated for other conditions

• Preventing blindness from diabetic retinopathy may be a strong motivator for diabetics to manage their own diabetes well and to attend for regular health checks


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• Older people make significant economic, social and emotional contributions to their families and communities

• But poor sight can limit their ability to contribute

• Adds to the burden of care for other family members, usually women, and limits carers’ participation in the paid workforce or their community

Poor sight inhibits older people playing productive roles in their families and communities:


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• Elders’ Clubs provide opportunities to reach older people with screening and referral for cataract surgery, spectacles, or other eye care

• facilitate discussion of eye health promotion messages

Healthy ageing programs and activities can contribute to improved vision:


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Re-orienting health systems for older patients and chronic conditions - important to advocate inclusion of eye health

• procurement of commodities - include intra-ocular lenses, spectacles and essential eye medicines

• health information systems and personal health records -include space for recording visual acuity and results of eye screening

• include eye health in health worker training, and in management and referral protocols

• make health facilities accessible to older people with poor vision, including provision of suitable transport


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• Strengthening systems for cataract surgery can provide lessons about strengthening health care systems for other types of surgery

• Need for surgery increasing with population ageing • Two billion lack access to surgery worldwide

Funk L, et al. Lancet 2010


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“A lot of people think that when this happens (cataract) to eyes it is the end of life, When you take them for surgery they feel like they are given another life”

[Young man, Agarapatana]

“When I was blind I felt like my hands and legs are not functional, now I can walk well and go anywhere, that is why I could come for this discussion too”

[Older woman, Agarapatana]

“In Mahauva, in a family one person was paid to look after the elder who had cataract. Now after surgery there is no need for a person to look after him.”


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“Only after the eye surgery I can see all the faces that I cannot see earlier, before 6 months for about 6 years I could not see, only now I am mobile, I can cook, prepare milk for my grandchild, get water from the tap, light the hearth. I have become functional in these 6 months.” [Older woman, Brookside estate]

“In Kahagalla, after the elder was operated for cataract, she came for the Elders’ Club meeting for the first time, and her daughter-in-law was able to go back to work.” [Community mobiliser]

“We have come from darkness to light” [Older man, Agarapatana]


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Achieving improved vision for elders

Better general health of

elders

Lessons learned on how to improve

health promotion and health systems for healthy ageing in

general

Elders contributing to health and well-being of children, youth and

adults

Reduced burden of care on family and

on government services

Improved quality of life and social participation

Improved development outcomes


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Thank you

Holbrook estate elders’ club

healthy ageing for eye health

Environment