The objective of this pilot study is to characterize the prevalence and consequences of cognitive impairment among Veterans receiving inter-disciplinary, outpatient low vision rehabilitation (LVR). This is a necessary first step toward future intervention and implementation research aimed at improving outcomes for Veterans with dual vision and cognitive impairments. Over 1 million Veterans are currently eligible for LVR and the VA provides excellent access to rehabilitation specialists and visual assistive equipment. However, little empiric evidence exists to guide efforts that may improve care for Veterans with both visual and cognitive deficits, and LVR protocols that address cognitive deficits are needed. The investigators' prior work in non-Veteran populations suggests that as many as 45% of LVR recipients are affected by some degree of cognitive impairment, and even mild cognitive deficits can compromise rehabilitation success. This team's long-term goal is to implement cost-effective LVR models that optimize functional outcomes for people with co-existing vision and cognitive impairments. In an affiliated academic center, members of our team developed and piloted a novel outpatient LVR program called Memory or Reasoning Enhanced Low Vision Rehabilitation (MORE-LVR) (Whitson et al, JAMA Ophthalmology 2013). Many features of MORE-LVR would be conducive to implementation in the VA and appealing to Veterans, but some aspects of MORE-LVR may not be compatible with the existing LVR infrastructure and practice patterns within the VA. This pilot study will serve as a necessary first step to enable future research by filling key knowledge gaps regarding cognitive impairment in VA LVR: there is a need to characterize the scope of the problem in VA Low Vision Clinics, to better understand VA-specific barriers and facilitators to improved services, and to select appropriate measures of intervention effectiveness in this population. This application proposes a 2-year observational study in the Low Vision Clinics of the Hines and Durham VA Medical Centers.
Aim 1 is to characterize the prevalence of cognitive deficits among Veterans receiving outpatient low vision services at these Durham and Hines VA Clinics. Study staff will administer 15 minutes of cognitive testing to a sample of 150-200 Veterans (75-100 at each site) who present for outpatient, inter- disciplinary LVR. From that sample, 40-50 Veterans (20-25 at each site) will be recruited to participate in a longitudinal cohort. Half of the longitudinal cohort will be Veterans whose test score indicates cognitive impairment; the other half will be age-matched Veterans with normal cognition. For each Veteran in the longitudinal cohort, a cognitively intact companion (friend or family member) will be enrolled to provide additional data about the Veteran's outcomes and experience in LVR.
Aims 2 and 3 will be accomplished by analyzing quantitative (Aim 2) and qualitative (Aim 3) data obtained from the 40-50 Veteran/companion pairs at baseline and 90-day visits.
Aim 2 will describe vision-dependent functional outcomes for patients with and without baseline cognitive impairment. The results will indicate the extent to which cognitive impairment may contribute to worse functional outcomes. Further analyses will compare various measures of vision-dependent function in this population.
Aim 3 will identify barriers and facilitators of successful rehabilitation through a content analysis of semi-structured interviews with patients and companions. These insights will inform the development of an LVR intervention that is compatible with the needs, resources, and expectations of the target Veteran and caregiver population. This pilot study is expected to lead to a controlled trial to assess whether a speciall designed LVR service achieves superior outcomes (compared to usual LVR) for dually impaired Veterans at acceptable incremental cost to the VA.

Public Health Relevance

Over 1 million Veterans suffer from vision loss that is incurable and severe enough to cause disability. As many as 45% of people with low vision also have cognitive problems that further threaten independence and cause challenges in rehabilitation. Due to the aging population and, in part, to the long-term consequences of combat-related injuries, an increasing number of Veterans are experiencing the combination of cognitive and visual deficits. This study will provide information about the scope, consequences, and potential solutions for this problem in the Veterans Health Administration, which is necessary to design services that reduce disability for Veterans with co-existing visual and cognitive problems.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (I21)
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Rehabilitation Research and Development SPiRE Program (RRDS)
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Durham VA Medical Center
United States
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Whitson, Heather E; Johnson, Kimberly S; Sloane, Richard et al. (2016) Identifying Patterns of Multimorbidity in Older Americans: Application of Latent Class Analysis. J Am Geriatr Soc 64:1668-73