Authors (including presenting author) :
Mak PT(1), Hui HM(1), Ho WL(2), Ng CM(2), Lam WC(2), Yau SF(1), Chan HF(1), Ng MY(2)
Affiliation :
(1) Department of Occupational Therapy, Grantham Hospital (2) Department of Ophthalmology, Grantham Hospital
Introduction :
According to the report in the HKSAR Census and Statistics Department in December 2014, there were 174,800 people having visual impairment, which accounted for 2.4% of the total population and 76.5% of this group aged 65 or above. Since 2016, Ophthalmology Specialist Outpatient Services in HKWC have been relocated to Grantham Hospital - Lo Fong Shiu Po Eye Centre, mainly providing eye screening and consultation by ophthalmologist and optometrist. However, eye patients with deficits in Activities in Daily Living or cognition could hardly receive rehabilitation in the clinic. Occupational Therapy (OT) service for elderly with subnormal vision in Grantham Hospital (GH) was also limited in the past and there was no structured assessment, evaluation nor intervention provided.
In December 2020, the Institute of Advanced Allied Health Studies (IAAHS) provided a commission training course on Visual Rehabilitation to Occupational Therapists, which further enriched our knowledge and vision to this group of clientele. Literature revealed that older adults with subnormal vision would have more difficulty in performing Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) compared to others (Crews & Campbell, 2001). In addition, subnormal vision in the older adult population often occurred with comorbidities such as cognitive decline. (Perlmutter, Bhorade, Gordon, Hollingsworth, & Baum, 2010) To develop the OT service for Subnormal Vision Rehabilitation in GH, we have collaborated with the Department of Ophthalmology in July 2021 and started a pilot program in September 2021.
Objectives :
To 1) develop OT service for elderly eye patients in GH; 2) maximise their functional vision level in ADLs /IADLs, cognitive function, awareness in fall prevention, home safety and promotes active living in community.
Methodology :
Patients who met the following criteria would be screened by Optometrists and referred by Ophthalmologists in the eye clinic for this pilot program: 1) Aged 65 or above; 2) Subnormal vision with pinhole Visual Acuity (VA) in better eye ≤ 0.2; and 3) No improvement in VA in two consecutive post-op follow-up. However, patients who had eye surgery post-op within 1 month or on active recovery with improvement in VA were excluded from this pilot program. A number of 1 to 4 OT out-patient individual sessions would be provided based on patients’ needs and assessment results. Intervention included functional and adaptation training on ADL/IADL, cognitive training, education on home safety, and fall prevention. Skills training on using mobile apps and vision assistive devices, such as magnifiers or devices with audio output, would be provided for promoting active living in the community. In addition, Community Occupational Therapy (COT) service with onsite home assessment would be conducted to the indicated cases, to enhance patients’ home safety via the home modification with regards to the problem of low lighting, poor contrast, or hazards of fall. Chinese Version of the National Eye Institute Visual Function Questionnaire (CHI-VFQ-25), HK-MoCA 5-min Protocol, Depression, Anxiety and Stress Scale 21 (DASS-21), Fall Risk Assessment Tool (FRAT), and Home Environmental Lighting Assessment (HELA) were used as outcome measures for functional vision performance in ADL/IADL, cognitive function, psychosocial status, fall risk, and home safety before and after the program.
Result & Outcome :
A total of 11 patients were referred from the eye clinic and 10 of them were recruited into the pilot program (Male/Female: 7/3, Age: 65-85, Median= 77.5). A total of 30 training sessions and 5 COT sessions were provided from September 2021 to March 2023. Diagnosis varied from Amblyopia (n=1), Advanced Glaucoma (n=2), Retinitis Pigmentosa(n=2) and Macular Degeneration(n=4), Micropsia (n=1). Among these 10 recruited patients, all of them had completed the initial assessment but only 4 of them had finished the whole program in March 2023 due to emergence of the fifth wave of COVID-19. By studying the raw data of pre-assessment, results showed that all cases had deficits in functional vision in ADL/IADL (CHI-VFQ-25: 29.6-60.6 out of 100). For cognition, eight of them scored within the normal range (≥16th), one of them scored consistently with Mild Cognitive Impairment (≤7th) and one of them scored consistently with Major Neurocognitive Disorder (≤2nd) diagnostic criteria. Concerning the fall risk, results indicated that all of them had low risk of fall (FRAT= 5-11 out of 20). For the psychosocial aspect, seven of them scored in the normal range in depression, two of them scored consistently with moderate risk and one with severe risk. In the anxiety and stress aspect, seven patients scored in the normal range, and three patients scored in the mild, moderate, and severe range respectively in both aspects.
For cases who had completed the program, intervention provided included functional and adaptation training on ADL/IADL, cognitive training, home assessment and modification, as well as lifestyle redesign. Results showed improvement in CHI-VFQ-25-Composite Score (Median= 45.2 to 50.7; IQR: 25.2 to 26.4), DASS-21-Stress Domain (Median= 6.5 to 4.5; IQR= 7 to 2), and FRAT Score (Median= 8 to 7; IQR= 4 to 2). The pilot program showed a positive impact on functional vision in ADL/IADL, psychosocial, and fall risk to certain extent. In conclusion, this pilot program is laying the foundation stone for the development of Occupational Therapy service for elderly patients with subnormal vision in GH. In future, we would keep collaborating with the Department of Ophthalmology and promote the number of referrals. Further data study would be carried out with more cases referred and assessed in future.
