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Correspondence: Please send correspondence to Jennifer Tolman, c/o Robert D. Hill, Department of Educational Psychology, University of Utah, 1705 Campus Center Drive, Room 327, Salt Lake City, UT 84112-9255. E-mail: jennifer.tolman{at}hsc.utah.edu
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Key Words: Vision loss • Depression • Eye disease • Legally blind
Of the diseases of the eye, ARMD is a leading cause of irreversible vision loss in persons over the age of 65 years, and it is the most common cause of legal blindness in old age (La Cour, Kiilgaard, & Nissen, 2002; Seddon & Chen, 2004). Nearly 13 million Americans older than 40 years of age could meet the diagnostic criteria for ARMD. In those older than 65 years of age, 1.2 million persons in the United States are legally blind as a result of ARMD; among older adults who are older than 75 years of age, over one third are afflicted with ARMD (Prevent Blindness America, 1994). Although the etiology of ARMD is unknown, there are predisposing factors that have been identified as predictors of the disease; these include heredity, advanced age, smoking, obesity, and gender (Seddon & Chen). Women who are over the age of 75 years are twice as likely to develop ARMD as men (La Cour et al.; Seddon, 1996).
ARMD occurs when the cells of the macula deteriorate, causing a loss of central vision. There are two types of ARMD, dry (or nonexudative) and wet (or exudative). Nonexudative ARMD is characterized by the initial appearance of small, round, usually elevated deposits in the macula called drusen. These features are diagnostic precursors to the rapid deterioration of the macular cells. Nonexudative ARMD accounts for approximately 85% to 90% of ARMD diagnoses (Gass, 1997; Seddon & Chen, 2004). Although, at present, there is no medical treatment available for nonexudative ARMD, it has been suggested that a diet rich in antioxidants such as zeaxanthin and lutein may lower the risk of early onset (Bernstein et al., 2002; Gellermann et al., 2002; Mares-Perlman, Millen, Ficek, & Hankinson, 2002). The exudative form, which accounts for the remaining 10% to 15% of ARMD diagnoses, is caused by the proliferation of abnormal vessels or choroidal neovascularization, which results in sudden and significant central vision loss or profound peripheral visual distortion (Gass; Seddon & Chen). Ferris, Fine, and Hyman (1984) found that those with profound visual impairment (20/200 or worse) generally suffer from exudative ARMD. Although new medical interventions such as photodynamic therapy (Haddad, Coscas, & Soubrane, 2002; Sickenberg, 2001; Woodburn, Engleman, & Blumenkranz, 2002) have shown promise for mitigating the progressive nature of exudative ARMD, there is essentially no treatment that can reverse eye damage and the consequent vision loss caused by this form of ARMD. Characteristically, nonexudative ARMD impacts central vision, leaving some residual peripheral vision. However, in the case of severe hemorrhaging with exudative ARMD, peripheral vision can be affected as well (Tani, Buettner, & Robertson, 1980).
Despite any existing residual peripheral vision in a person with ARMD, on a practical level, the inability to accomplish instrumental activities of daily living, including the ability to read bank statements or medication labels, write checks, and pay bills, can disrupt the person's sense of intrapersonal control, particularly in a community-dwelling individual who has previously enjoyed an autonomous lifestyle. The vision-related lack of mobility that accompanies loss of driving privileges and the inability to recognize others' faces also may lead to social isolation, which could, in turn, produce symptoms of depression in an otherwise nondepressed individual. Inaccurate social stereotypes associated with disease-related vision loss could disrupt interpersonal relationships, which may also contribute to depressive affect.
Because depressive symptomatology often accompanies ARMD, clinical depression is a common collateral diagnosis (Burmedi, Becker, Heyl, Wahl, & Himmelsbach, 2002; Kleinschmidt, 1995; Leinhaas & Hedstrom, 1994; Robbins & McMurray, 1988). The nature of depressive affect, however, has not been sufficiently examined in older adults suffering from ARMD, including its relationship to perceived visual adaptation as measured by validated adaptation-assessment tools (Horowitz, 1995). Though many studies have examined the psychological consequences of disease-related vision loss in old age, researchers have used a variety of methodologies and have not discriminated participants with respect to eye disease diagnosis or measured visual acuity. These studies, for the most part, have not controlled for mediating variables such as general health status (Burmedi et al.). As noted by Burmedi and colleagues, it may be useful to disentangle these factors by selectively examining more homogenous samples of older adults with disease-related vision loss given that the onset, course, and treatment of different eye pathologies varies.
Cherry, Keller, and Dudley (1991) reported a cross-sectional study of 303 persons with visual disabilities. Among the subset of adults 70 years and older, loss of sight was correlated with poorer self-confidence, decreased perceived autonomy, and a diminished social network. Eye pathology was not controlled in this study. Loss of internal locus of control has been found to correlate with higher levels of depressive affect, particularly if such deficits are perceived to result in a loss of personal freedom and control (Kleinschmidt et al., 1995). In a 6-month longitudinal study, Rovner and Casten (2001) found that ARMD patients who developed depression as a result of their visual impairment were more likely than nondepressed patients to become functionally disabled as a result of their vision loss.
With respect to adaptation, Conrod and Overbury (1998) suggested that challenging negative global self-attributions often involves learning new, adaptive responses to vision loss. Following this line of reasoning, Horowitz, Leonard, and Reinhardt (2000) reported differences in psychosocial adjustment, depression, life satisfaction, and functional ability in 395 legally blind older adults (55 years and older) who participated in a training course on adaptive skills training. Their findings suggested that it may be important to address psychosocial needs in order to achieve optimal treatment benefits. Jose (1983) noted that persons with visual impairment may report benefiting from the support that family, friends, and helping professionals provide in positively reframing negative self-perceptions about their loss of sight. In a study conducted on ARMD patients, Wahl, Becker, Burmedi, and Schilling (2004) found that selective primary control (the investment of internal resources such as time and effort) was related to better functioning; they also reported that the availability of external resources for help was related to positive affect. Rovner and Casten (2002) found that activity loss mediated the relationship between visual acuity and levels of distress related to vision loss, and that distress increased as individuals relinquished valued activities as a result of their visual impairment.
One issue that has made it difficult to measure successful psychosocial adaptation to profound vision loss is the absence of reliable and valid instruments designed to assess adaptation. Horowitz and Reinhardt (1998) developed a scale to measure adaptation to vision loss specific to older adults. Using the Adaptation to Vision Loss Scale (AVL), a more precise examination of an older person's psychological adjustment to vision loss is possible. Our purpose in the current study was to examine psychosocial adaptation in legally blind ARMD adults, including acceptance of the vision loss, attitudes toward relationships with family members and friends, and attitudes toward rehabilitative training. This study specifically examined the relationship between depressive symptomatology and measured psychosocial adaptation to vision loss in individuals who were legally blind. Of interest was whether intrapersonal or interpersonal aspects of vision-loss adaptation were associated with self-reported depressive symptomatology in a sample of community-dwelling older adults who were formally classified as legally blind as a result of ARMD.
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Measures
Self-reported demographic information obtained from each participant included age, gender, years of education, and yearly income. Interviewers asked participants whether they engaged in state-provided services for the blind and visually impaired, such as attending classes, listening to books on tape, attending community support groups, and using telephone services, such as directory assistance and operator-connected calling. They also asked participants whether they used rehabilitative devices such as talking watches, magnifiers, and computer aids. In the regression analysis, we computed and utilized a simple sum score that included the number of services being accessed and devices being used. We collected information about ARMD, including time since first diagnosis and type of ARMD (e.g., wet or dry or both). We also had three standardized instruments administered, including the Short Portable Mental Status Questionnaire (SPMSQ; Pfeiffer, 1975), the short form of the Geriatric Depression Scale (GDS-SF; Sheikh & Yesavage, 1986) and the AVL (Horowitz & Reinhardt, 1998).
We used the SPMSQ to determine the level of cognitive functioning at the point of testing and to screen for cognitive impairment. We categorized participants by number of errors made on the SPMSQ, and we considered a score of five or more errors to be indicative of cognitive impairment.
The GDS-SF assessed self-reported depressive affect and, although it has not been normed on visually impaired persons, the GDS-SF has been used on a wide variety of older populations (Sheikh & Yesavage, 1986). It uses a dichotomous scoring system to elicit information about energy level, social interaction, mood, and hope for the future. Utilization of a yes–no format makes it ideal for older visually impaired adults who may have difficulty completing a Likert-type response format. The total GDS-SF score indicates the following: 0–5 = nondepressed; 6–10 = mild depressive symptoms; 11–15 = severe depressive symptoms (see Sheikh & Yesavage). For this study, we treated the GDS-SF score as a continuous variable with an absolute range between 0 and 15.
We used the AVL to assess each participant's degree of psychosocial adaptation to visual impairment. The AVL is a 24-item dichotomous scale (e.g., agree–disagree), developed specifically for visually impaired older adults. AVL questions address one's acceptance of vision loss, attitude toward relationships with family members and friends, and attitude toward rehabilitative training (Horowitz & Reinhardt, 1998). Correlations of r =.49, r = –.55, and r =.45, respectively, have been reported in previous studies that used the AVL in relation to a life-satisfaction inventory, a depressive-symptomatology measure, and a self-rated item of adaptation to vision loss. These findings were interpreted as supporting the authors' hypothesis that adaptation to vision loss is a component of overall subjective well-being (Horowitz & Reinhardt). Of the 24 items, 19 are phrased in the negative direction (e.g., "Visual impairment is the cause of all my problems") and 5 are phrased in the positive direction (e.g., "There are worse things that can happen to a person than losing vision"). A score of 1 represented an agree response on the negatively stated items and a score of 0 represented a disagree response. For the positively stated items, a score of 1 represented a disagree response and a score of 0 represented an agree response. Higher AVL scores indicate poorer adaptation to vision loss. For the purpose of this study, we constrained the definition of adaptation to a person's level of adjustment to vision loss at the point of responding to the AVL.
Procedures
As patients with a diagnosis of ARMD were seen in the Retina Clinic, once it had been determined that their visual acuity was 20/200 or less in both eyes, they were invited to participate. For those who volunteered, informed consent was then read and explained, followed by the administration of self-report measures. These were administered before the completion of the clinic visit, or, if more convenient for the patient, at a later date by telephone interview.
One hundred and fifty-four outpatients were invited to take part in the study. Of the 152 who volunteered to participate, who qualified medically, and who met the diagnostic criteria and ARMD visual impairment criteria of 20/200 in both eyes, 2 reported recent major life events that could have affected their self-report of mood (e.g., death of a spouse, recent diagnosis of a terminal illness). We excluded these outpatients. We screened 4 additional participants from the study because they had deficits in cognitive functioning or an SPMSQ score that exceeded the cutoff of five or more errors. Two participants who met all the criteria dropped out before completion of the measures, leaving 144 individuals with complete data who also met all of the inclusion criteria for study participation.
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We further evaluated the 24 AVL questions by using an exploratory principal components analysis with varimax rotation. The results of this analysis, along with a description of each AVL item with respect to the factor to which it is most closely aligned, are depicted in Table 1. The most distinguishing factor with respect to variance explained (22.27%) involved 12 questions related to one's acceptance of vision loss. The second factor, explaining an additional 9.2% of the variance, highlighted 9 items related to the individual's perception of how visual impairment negatively affects relationships with family and friends. The third factor, accounting for 7.2% of the explanatory variance, comprised 3 items related to one's attitudes toward compensation for visual impairment.
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With respect to the measurement of adaptation to vision loss used in this study, Horowitz and Reinhardt (1998) hypothesized that the AVL would encompass three distinct psychological responses: acceptance of the loss, attitudes toward interpersonal relationships, and attitudes toward loss compensation. Although the lack of consistency in factor loadings that they found across several studies led Horowitz and Reinhardt to conclude that the AVL may be most useful as a unidimensional measure, our factor analysis indicated the presence of more than one factor that contrasted the intrapersonal and interpersonal aspects of coping. This difference may have been attributable to specific characteristics of our sample, namely, that it was composed of only ARMD patients. The two intrapersonal or internal coping factors, namely acceptance of and compensation for vision loss, were more related to depressive affect than the interpersonal factor or the impact of vision loss on friends and family. This latter finding suggests that the central emotional feature underlying depressed mood in vision impairment in these ARMD patients appeared to be the phenomenological or internal experience of vision loss as opposed to how the participants perceived that their blindness was impacting social or family relationships.
The existing literature has yet to contrast the intrapersonal and interpersonal experience of visual impairment in old age as it relates to depressive affect; therefore, this study provides preliminary evidence that supports the importance of internal processes as they relate to depressive symptomatology in older adults who are visually impaired as a result of a progressive eye disease. From a practical standpoint, this finding also suggests that it may be important, when one is gauging the affective response to vision loss in an older person who is visually impaired as a result of ARMD, to consider internal coping resources as one potential explanatory factor of depressive (or negative) affect.
A secondary finding was the correlation between depressive affect and frequency of services used. As noted in Table 1, depressive symptomatology was negatively correlated with the number of rehabilitative services a participant reported accessing. This was also the case for all three AVL factors scores. Further, service utilization was a substantial predictor of depressive affect after we controlled for participant demographics. In this study, service use was primarily used as a control variable that assessed the extent to which these patients were addressing their vision impairment. However, it may be profitable in future research to consider the extent to which adaptation to vision loss impacts service utilization in older adults, including those with less severe vision impairment caused by ARMD, as well as those with other eye pathologies, and the impact of depressive affect on these relationships. This may require developing a measure that assesses both the frequency and perceived utility of rehabilitative services for the blind.
The findings from this study are primarily exploratory for several reasons. First, the sample was confined to noninstitutionalized, healthy, White older adults from the Western United States who had access to private health insurance. Second, this sample consisted of an unusually motivated group of older adults who were actively seeking out and receiving treatment for ARMD, and the majority (85.4%) reported accessing one or more rehabilitative service. Therefore, these findings characterize primarily older persons who are engaged in efforts to remediate the limitations associated with their visual impairment. Third, because participants were required to be legally blind in order to qualify for the study, it was necessary for the questionnaires to be read to the participants by an examiner; thus, social desirability may have produced a response bias. It also should be noted that the cross-sectional nature of this study limits the findings to associations between AVL scores and self-reported depressive affect at a single point in time and, for this reason, the relationship between depressive affect and vision loss adaptation should be interpreted cautiously. Finally, because all of the participants in this sample were legally blind with their best-corrected vision ranging from 20/200 to no light perception, the generalizations of the study are limited to only those with very little residual or nonexistent perceptual vision.
Practice Implications
This study provides preliminary evidence suggesting that legally blind older adults with ARMD who are more adapted to their vision loss report less depressive affect. Further, the intrapersonal experience of vision loss was the most explanatory feature of adaptation as it related to depressive symptomatology in these patients. Health care providers need to inform their patients that there are meaningful ways to cope with ARMD-induced vision loss. This study suggests that practitioners also should be mindful of a patient's intrapersonal perception of visual impairment, particularly as it relates to the propensity to access rehabilitative services or therapy as a means of helping their patients remain happy and productive in the presence of profound vision loss.
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2 Department of Ophthalmology, University of Utah, Salt Lake City.
Decision Editor: Linda S. Noelker, PhD
Received for publication November 11, 2004. Accepted for publication June 13, 2005.
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