Possession of Low Vision Reading Devices Among Residents Living in a Retirement Facility

Abstract

Introduction: The purpose of this cross-sectional survey was to examine the possession of low vision reading devices and factors associated with possession of these devices among residents living in a continuing care retirement community. Low vision reading devices are devices other than eyeglasses that aid in reading at near distances. Methods: One hundred and two usable questionnaires were received from residents, ages 65–97 years old, living in the independent and assisted living units of a retirement community. Results: Data indicated that 47% the participants reported having an eye disease, and 53% of the participants owned at least one low vision reading device. The two most common types of devices were handheld magnifiers (40%) and gooseneck lamps with or without a magnifier (26%). Of the 48 participants reported to have eye disease diagnoses, 65% owned a reading device. Forty-six percent of the participants reported having trouble with reading when performing one of the six daily activities even with their reading eyeglasses. The final multivariable logistic regression model indicated that participants who reported having trouble with reading in near distance were significantly more likely to own one of the reading devices. Discussion: This study identified a discrepancy between the high prevalence of visual impairment (i.e., blindness and low vision) among residents living in a retirement community setting and a relatively low number of residents owning low vision reading devices. Findings suggested the key factor contributing to residents’ decision to own reading devices is their level of visual impairment. Implications for Practitioners: Knowing the factors to owning low vision reading devices, occupational therapists may assist residents in continuing care retirement facilities to obtain the appropriate devices.

Keywords

activities of daily living low vision occupational therapy and self-help devices

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With an increase in age, older adults are more likely to experience visual impairment (Chan et al., 2018; Massof, 2002). Those with visual impairments affecting central vision report having difficulty with near vision tasks such as reading print in newspapers, magazines, menus, recipes, numbers on the telephone, or distance vision tasks as in recognizing a friend across the street (Weih et al., 2002). Much of the visual impairment in older adults is due to correctable conditions such as refractive error (e.g., presbyopia) and cataract (Schneider et al., 2010). However, visual impairment can reduce older adults’ level of participation in daily activities, social roles, and their independence in community living (Desrosiers et al., 2009; Jin & Wong, 2008). Some older adults with visual impairment may decide to move into continuing care retirement communities (hereafter, retirement communities), establishments that include both independent living and assisted living facilities (Elliott et al., 2013).

Among residents living in assisted living facilities, cataracts, glaucoma, age-related macular degeneration (AMD), and diabetic retinopathy are the most common visual impairment diagnoses (Elliott et al., 2013). Of these diagnoses, AMD is the most common cause of low vision in older adults, especially those older than 80 years (Chan et al., 2018). Low vision is a chronic disabling condition with bilateral visual impairment that cannot be fully corrected by refractive means, surgery, or medication, and that interferes with daily activities (Lee & Mesfin, 2019). According to the World Health Organization’s classification of visual impairment (WHO Programme for the Prevention of Blindness and Deafness, 2003), low vision is defined as a visual acuity of worse than 20/60 in the better seeing eye, even with the use of corrective lenses.

Difficulties in performing near vision tasks have been identified in more than 25% of community-dwelling older adults in the United States because of visual impairment (Zebardast et al., 2017). Difficulty with reading is one of the most common clinical complaints among older adults with central vision loss (Markowitz et al., 2018). To compensate for visual impairment when performing near vision tasks such as reading, older adults may use low vision devices that assist with illumination, contrast enhancement, magnification, and glare control (Natarajan, 2013).

Adults with visual impairment require at least double the illumination levels of typical room lighting and significantly more than usual home lighting to perform daily activities (Falkenberg et al., 2019). Better and supplemental lighting has been shown to improve the ability of community-dwelling older adults to complete meaningful daily activities that they previously stopped performing due to insufficient illumination (Falkenberg et al., 2019). Improved illumination also enhances contrast, which enables older adults to visualize contextual features more distinctly and function more safely in their living environment (Broussard, 2019). In addition to supplemental lighting, magnification of objects improves the ability of older adults with central vision impairment to complete near vision tasks such as reading (Nguyen & Trauzettel-Klosinski, 2009; Smallfield et al., 2013), as larger print sizes are required to compensate for the physiological reduction in acuity which occurs with increasing eccentricity from the fovea (Battista et al., 2005).

Low vision devices include magnification devices such as optical magnifiers, which provide angular magnification via traditional plastic and glass lenses, and electronic magnifiers. Optical magnifiers are found in both handheld and stand formats; electronic magnifiers include desktop closed-circuit televisions (CCTVs) that project reading materials on a large display screen, and portable electronic magnifiers which typically have a much smaller display. Low vision devices are also available through non-optical means (such as supplemental lighting), enlarged print materials and enlarged numbered devices, and assistive technology (such as text-to-speech devices). Among older adults with visual impairments, optical magnifiers have been reported to be one of the most frequently used devices to aid reading (Carkeet, 2019; Gobeille et al., 2018; Lew et al., 2015). Overall, the use of low vision devices to compensate for visual impairment is a simple and effective means to reduce degree of disability, improve vision-specific quality of life (Heravian et al., 2016) and reading ability (Choi et al., 2018; Patodia et al., 2017), though evidence for the use of vision-specific assistive technology such as optical magnifiers to improve reading performance of daily tasks is low (Smallfield et al., 2013; Smallfield & Kaldenberg, 2020)

Ownership of prescribed low vision devices, as well as factors associated with their use, has been examined in older adults with low vision (Lorenzini & Wittich, 2020). Studies on the use of prescribed low vision devices consistently support that older adults with low vision demonstrate high rates of regular or daily use of the assistive devices for months, with infrequent abandonment (Fok et al., 2011; Gobeille et al., 2018). For example, the handheld magnifier abandonment rate was less than 4% at 1 year follow-up (Gobeille et al., 2018), indicating that these devices are consistently utilized by clients with low vision, even a year after obtainment.

Ownership and prevalence in the use of low vision devices among older adults without low vision diagnoses has also been examined (Mann et al., 1993; Orellano-Colon et al., 2018; Sonn & Grimby, 1994). Devices for vision were found to be some of the most frequently needed assistive devices reported by community-dwelling older adults (Gitlow et al., 2012). In particular, magnification devices were one of the most frequently identified assistive devices that these older adults needed (Gitlow et al., 2012). This is supported cross-culturally as Orellano-Colon and associates (2018) found that 30% of the surveyed community-dwelling Hispanic older adults owned a handheld magnifier. In summary, the literature supports that traditional low vision devices, with or without prescription, are used by older adults without low vision diagnoses.

Although previous studies have investigated the prevalence of visual impairment among residents living in assisted living facilities (Elliott et al., 2013) and the use of low vision reading devices (hereafter, reading devices) in older adults with and without low vision diagnoses living in the community (Gitlow et al., 2012; Gobeille et al., 2018; Lorenzini & Wittich, 2020; Orellano-Colon et al., 2018), there is limited research on studying the prevalence of the ownership and use of reading devices specifically among older adults living in retirement community settings. The prevalence of visual impairment (i.e., blindness and low vision) in this population is much higher than those living in the community (Zebardast et al., 2017), with almost 90% of residents living in retirement communities identified as having a visual impairment (Elliott et al., 2013). Therefore, the purpose of this study is to investigate the possession of reading devices and the factors associated with the possession of these devices in a group of retirement community residents.

Method

Design

This descriptive study involved a cross-sectional survey research design in which analysis of data of variables was collected at one given point in time across a study sample. The research questions were: (1) What is the prevalence of retirement community residents who possess low vision reading devices? and (2) What factors are associated with the possession of these devices in a group of retirement community residents?

Participants

Participants who were eligible for the study were residents in the independent living and assisted living units of a retirement community in Des Moines, Iowa. Participant inclusion criteria for this study were as follows: 65 years of age or older, and the ability to complete the survey questionnaire without total reliance on others (suggestive that participants were not cognitively impaired). At the time of survey dissemination, there were 135 residents in the independent living units and 49 in the assisted living unit, for a total of 184 residents, ranging in age from 65 to 102 years old.

Procedures

The first author contacted the Wellness Director of the continuing care retirement facility and obtained permission to distribute the survey to the residents. Information about the purpose of the survey study was announced in one of the monthly update meetings at the retirement facility, which is open to all residents. After the meeting, the survey was distributed to all 184 residents through internal mail slots with an envelope in which the survey could be sealed when returned. Secured boxes for survey returns were placed in two predetermined convenient locations in both the independent living and assisted living units of the facility. Residents were given 30 days to respond to the survey. Flyers were posted in the facility a week before the deadline to remind residents of the survey return deadline. Responses to the survey questionnaire were anonymous. Resident participation in the survey was entirely voluntary with no incentive. The research was approved by the Institutional Review Board at the University of Alabama at Birmingham.

Instrument

The survey questions used in this study were part of a larger study designed to gather information regarding home environment, fall risk, owning or use of assistive devices (including low vision devices and non-low vision devices), and self-reported functional limitations or abilities to perform daily activities related to, as well as not related to, visual impairment among residents living in a retirement community. The survey had 28 questions, including socio-demographics information. The survey was developed by the first author. Three occupational therapy university faculty, two with expertise in low vision, reviewed the survey and offered feedback on the content. The survey was revised to incorporate recommended changes. Considering the population of older adults that would be taking the survey, the text was printed in 18-point Calibri font to make the survey more accessible for residents with low vision who did not have assistive devices with which to aid reading. It would take the residents about 30 minutes to complete the survey. The study was completed in mid-2014.

Of relevance to the current investigation was the inclusion of the following questions or items from the original survey that related to: socio-demographics of the residents including age, gender, length of stay in the current apartment, types of living unit (independent living vs. assisted living), and types of living arrangement (live alone vs. with someone). Questions related to eye diseases and prescription of low vision devices were self-reported: eye diseases (macular degeneration, glaucoma, diabetic retinopathy, and cataracts, not having had cataract surgery), and receipt of a prescription for low vision devices after a vision evaluation. Items related to reading devices included (1) optical magnifying devices, such as video magnifiers or closed-circuit televisions (CCTVs), handheld magnifiers, and stand magnifiers; (2) enlarged print materials or enlarged numbered devices such as large-number telephones or watches, and books with large print; (3) talking devices (e.g., audio- or Talking Book players); and (4) gooseneck lamps (with or without magnifiers) over a work area. In addition, six items related to trouble with seeing things in near distance (i.e., reading) when performing daily activities were included. They were using a telephone book and reading newsprint, mail, recipes, or food labels when cooking, and reading labels and price tags when shopping. Response options to all the non-demographic questions were either “yes” or “no.”

Data Analysis

Descriptive statistics were used to summarize the prevalence of self-reported eye diseases, trouble with seeing things in near distance (i.e., reading) when performing daily activities, and possession of reading devices. Comparisons of the proportion of participants between the eye disease and non–eye disease groups in having trouble with reading and possession of reading devices were conducted using the Fisher’s exact test. Multivariable logistic regression modeling was used to determine factors associated with the possession of reading devices among participants. The response variable was the possession of reading devices, which was derived from the questions or items related to the possession of devices for magnification, enhancing illumination, and converting text to speech. The explanatory variables included socio-demographics, self-reported eye diseases, receipt of a prescription for low vision devices after a vision evaluation, and trouble with reading when performing daily activities. To facilitate data analysis and interpretation, response to multiple questions or items within a category such as reading devices, self-reported eye diseases, and trouble with reading when performing daily activities were recoded. An affirmative (i.e., “yes”) response to one or multiple questions or items within each of these categories was coded as positive (1 = “yes”); otherwise, it was coded as 0 (“no”). Zero imputation (replacing missing values by zeros) was used as it is the most common approach when dealing with binary item nonresponse, and it creates little bias (Fraser et al., 2009; Sariyar et al., 2012). Missing responses to the selected questions or items were at most 5%.

Explanatory variables were initially screened for consideration in the model using bivariable association between each explanatory variable and the response variable. Explanatory variables were considered as candidates for inclusion in the multivariable logistic regression analysis if there was an association with the response variable (p-value < .15) in the bivariable analysis (VanderWeele & Shpitser, 2011). Explanatory variables with p-values < .05 were retained in the final multivariable logistic regression model. All data analyses were conducted using the Statistics Package for Social Sciences (SPSS) for Windows, version 23 (IBM Corp., Armonk, NY, USA).

Results

Of 184 surveys distributed, we received 103 completed surveys with a response rate of 56%; 24 were from residents in the assisted living unit (49% response rate) and 79 from the independent living unit (58.5% response rate). One completed survey from a resident in the assisted living unit was disqualified. The resident’s daughter completed the survey for the resident; she wrote on the survey that her mother had dementia, which jeopardized the validity of the response. The analytic sample consisted of 102 participants with usable data. The mean and standard deviation (SD) for age of the participants was 85.3 ± 6.7 years (range: 65–97 years) and the mean and SD length of stay in the current apartment was 6.5 ± 6.1 years (range: 1 month–25 years). There was no significant difference in proportion of residents living in the independent versus assisted living unit in self-reported eye disease (p = .34), trouble in reading (p = .63), receipt of a prescription for low vision devices (p = .37), and possession of reading devices (p = .81).Variables summarized by frequency / percentage of responses in total as well as by groups of having and not having self-report eye diseases are displayed in Table 1.

Table 1.

Characteristics of Participants (N = 102).

Characteristic	n	%
Female	70	68.6
Living alone	66	64.7
Independent living unit	81	79.4
Assisted living unit	21	20.6
Receipt of a prescription for low vision devices	21	20.6
Self-reported eye diseases (at least one)	48	47.1
Macular degeneration	21	20.6
Glaucoma	20	19.6
Cataract, not having surgery	16	15.7
Diabetic retinopathy	1	1.0
Low vision devices (own at least one device)	54	52.9
Hand-held magnifier	41	40.2
Gooseneck lamp (with or without a magnifier)	26	25.5
Number or letter size magnification	9	8.8
Stand magnifier	5	4.9
Talking devices	4	3.9
Video magnifier machine (CCTV)	2	2.0
Trouble with reading (one of the six daily activities)	47	46.1
Using a phone book	40	39.2
Reading labels when shopping	26	25.5
Reading newsprints	23	22.5
Reading price tags when shopping	15	14.7
Reading recipes or food labels when cooking	14	13.7
Reading mail	14	13.7

Overall, 47% of the participants reported having at least one of the four common types of eye diseases (i.e., AMD; glaucoma; diabetic retinopathy; and uncorrected cataract, without cataract surgery), with 37% of them reporting one diagnosis, and 10% two diagnoses. Forty-six percent of the participants reported having trouble with reading when performing one of the six daily activities. The three most frequent daily activities that the participants had trouble engaging with due to inability to see well (i.e., reading) were using a telephone book (39%), reading labels when shopping (26%), and reading newsprint (23%). All participants, except two, wore eyeglasses, including reading eyeglasses. Fifty-three percent of participants owned at least one type of low vision reading device: 29% owned 1, 16% owned two, 3% owned 3, 2% owned 4, and 3% owned 5. The two most frequent reading devices that the participants owned were handheld magnifiers (40%) and gooseneck lamps with or without a magnifier (26%).

Of the 48 participants reported to have eye disease diagnoses, 31 of them (65%) owned a reading device. A significantly higher proportion of participants in the eye disease group reported having trouble with reading when performing one of the six daily activities (p = .02), and possession of reading devices (p = .03) when compared to participants in the non–eye disease group. Of the 21 participants who had received a low vision device prescription, 10 (76%) had at least one reading device. More than 75% (10/13) of the participants with self-reported eye disease who received a prescription for low vision devices owned a reading device.

Factors Associated With the Possession of Reading Devices

The factor structure of the scale formed by the six items related to trouble with seeing things in near distance (i.e., reading) when performing daily activities was determined using an exploratory factor analysis with an unweighted least squares extraction method for categorical data (Bartholomew, 1980), resulting in one factor (unidimensionality) based on the eigenvalue >1 rule, and scree plot criteria. The factor explained 56.3% of the variance (eigenvalue = 3.38). The factor loadings of the six items were ≥ 0.67. The internal consistency reliability coefficients as estimated by the Cronbach’s alpha was 0.84 (95% confidence interval [CI] = .79–.88), which is considered to be good (George & Mallery, 2003). There was no increase in the alpha coefficient when an item was eliminated from the scale.

Univariate analyses indicated participants who reported living with someone (p = .09), having a longer length of stay in the facility (p = .04), having eye diseases (p = .03), receipt of a prescription for reading devices after a vision evaluation (p = .02), and having trouble with reading when performing daily activities (p < .001) were more likely to be associated with possession of reading devices.

Multivariable logistic regression analyses indicated that two factors were significantly associated with possession of reading devices among participants in the final model which were trouble with reading when performing daily activities (adjusted OR = 6.5, 95% CI = 2.3–17.9, p < .001), and length of stay in the facility (p = .04). The odds of the participants’ possession of reading devices were about 7 times greater for those who reported having trouble with reading when performing daily activities than those who did not report such trouble, controlling for other explanatory variables (see Table 2).

Table 2.

Multivariable Analysis Examining Factors Associated With the Possession of Low Vision Reading Devices.

Explanatory Variable	Adj OR	95% CI		p
		LL	UL
Trouble with reading in near distance	6.47	2.34	17.87	.001
Receipt of a prescription for low vision devices	1.47	.40	5.46	.56
Self-reported eye diseases	1.93	.75	4.99	.17
Length of stay in the facility	1.09	1.00	1.18	.04
Living alone	.60	.23	1.58	.30

Note. Adj OR = adjusted odds ratio; CI = confidence interval; LL = lower limit; UL = upper limit.

Discussion

The results of this survey indicated that a little more than half of the participants (53%) owned at least one reading device. Hand-held magnifiers are the most common type of reading device that the participants owned. The percentage of participants in this study who owned a handheld magnifier was 40%. This percentage is similar to the findings in a previous study (Orellano-Colon et al., 2018). Nevertheless, residents living in retirement communities have a much higher prevalence of visual impairments than community-dwelling older adults. For example, the prevalence rate of AMD and glaucoma in the present study was about 20% each, whereas among older adults aged at least 80 years in the general population, the prevalence rate of AMD was 9–12% and glaucoma was 7.5% (Gupta et al., 2016; Klein & Klein, 2013). In particular, a higher proportion of older adults in our sample (47%) reported having eye diseases compared to Orellano-Colon et al.’s study (25%). It is possible that this is related to the higher incidence of AMD in non-Hispanic whites as opposed to glaucoma, which disproportionately affects Hispanic and African American populations (Klein & Klein, 2013). Therefore, it is unclear why the proportion of residents in this study who owned reading devices is similar to that of community-dwelling older adults in the Orellano-Colon study.

It appears that about a quarter of participants with a self-reported eye disease (27%) received a prescription for low vision devices. Given that more than 75% of the participants with self-reported eye disease who received a prescription for low vision devices owned a reading device, it is important for residents with eye disease to have a vision evaluation and receive a prescription for an assistive device. On the other hand, of the 48 participants reported to have an eye disease, 31 (65%) of them owned a reading device. Given that possession of reading devices has been shown to be significantly associated with having trouble with reading when performing daily activities, it is important to understand why such a large percentage of participants (35% or 17) who reported having an eye disease did not report owning any reading devices. As revealed in the present study and other literature, older adults are open to accepting recommendations from low vision specialists about obtaining reading devices. Many barriers exist for obtaining low vision services, including lack of awareness of services, transportation, and misperceptions about the ability to participate in instrumental activities of daily living (Pollard et al., 2003; Southall & Wittich, 2012). With an understanding of the barriers of owning reading devices, occupational therapists may better assist residents in retirement communities to obtain the appropriate device.

As indicated, besides handheld magnifiers, gooseneck lamps and number or letter size magnification, very few participants (less than 5%) owned other types of reading devices. Magnification and lighting devices can be easily purchased from a variety of sources without prescriptions. Even though video magnifiers such as stand-based electronic magnification have been shown to improve reading speeds and duration of reading in adults with low vision (Smallfield et al., 2013; Smallfield & Kaldenberg, 2020; Virgili et al., 2018), these systems are much more expensive than handheld magnifiers, and low vision devices are not routinely covered by public or private insurance (Choi et al., 2018).

The final multivariable logistic regression model indicated that participants who reported having trouble with reading in near distance were significantly more likely to own a reading device. Results are consistent with the literature that an increase in the possession of reading devices was associated with a decrease in near vision acuity (Gibson, 2018), and the key factor contributing to influence older adults’ decision to own and use reading devices is their level of visual impairment (Lorenzini & Wittich, 2020).

Contribution to Vision Science

Findings from this study contribute to a better understanding of the need for reading devices and the determinant of owning reading devices (i.e., trouble with reading in near distance) among residents living in retirement communities. To the best of our knowledge, as of today, no studies have investigated the possession of reading devices among residents living in retirement communities. This study identified a discrepancy between high prevalence of visual impairment among residents living in a retirement community and a relatively low number of residents who owned reading devices. Also, a high percentage of participants (35%) who reported having low vision did not own any reading devices. Multivariable regression analysis also confirmed that low vision is not uniquely associated with possession of reading devices among residents living in a retirement community. Findings and questions generated from the present study may facilitate the development of a new line of scientific inquiry on visual impairment and reading devices among residents living in a retirement community; for example, investigation of the unmet needs of low vision services (including recommendation of reading devices) among residents in retirement communities who may or may not have low vision diagnosis; and transition the use of handheld magnifiers to mainstream technology such as smartphones (Crossland et al., 2014).

Limitations and Recommendations

There were several limitations to the study. First, no eye exam was conducted to confirm participants’ self-reported eye disease; however, the percentages of self-reported macular degeneration (20%) and diabetic retinopathy (1%) in this study were similar to the diagnosed percentages reported in Elliott et al.’s study, which was 23.1% for macular degeneration and .7% for diabetic retinopathy, with n = 144 (Elliott et al., 2013). This comparison (p = .87, Fisher’s exact test) suggests that the self-reported data in this study may be a valid measure of actual eye disease. Second, there was no formal cognitive assessment completed prior to administration of the survey. Even though cognitive impairment among residents living in assisted living unit is common, if residents could follow the instructions to complete and submit the survey without totally relying on others, this may indicate that the participants are not likely to have cognitive impairment. Responses to the survey questions were relevant to the context, which may indicate that the participants have the reading comprehension skills to answer the questions appropriately. Third, for the choice option of reading devices in the questionnaire, we included gooseneck lamps with and without magnifiers, but not handheld magnifiers with a light source. As indicated in the literature, increased illumination may aid reading (Evans et al., 2010; Smallfield et al., 2013); therefore, future studies should include this option. Lastly, this study was limited by a small sample size. The sample was taken from a single retirement community, which may limit the ability to generalize the findings. It is recommended that future studies should include cognitive assessment, eye examination and verification of the frequency of use of the reading device.

Conclusion

The findings of this study suggest that low vision reading devices are not exclusively beneficial for retirement community residents with self-reported eye disease. Residents may benefit from reading devices due to natural age-related changes in the eye. Since the prevalence of age-related eye disease among residents in retirement communities is much higher than in community-dwelling older adults, occupational therapists should be prepared to recognize functional impairments associated with vision loss, select intervention strategies, and make referrals to appropriate vision specialists. This recommendation supports the ability of older adults to maintain independence, function, and successfully age in place. For retirement community residents with visual impairments, the ability to perform essential reading tasks when performing activities of daily living, such as reading package directions and seeing appliance settings for meal preparation or reading prescription labels for safe medication management, could mean the difference between the ability to remain living in an independent living setting as opposed to transitioning to an assistive living setting with a higher level of care.

To apply these findings, occupational therapists should provide residents living in retirement communities access to reading devices that will help them perform their desired tasks, which should include identifying information about resources for reading devices, educating them about the many commercially available reading devices including portable electronic devices for vision enhancement, and training them to make the best use of reading devices. Any health care provider in a retirement community who interacts with a resident experiencing functional visual challenges should refer that person to appropriate eye doctors and low vision specialists. Additionally, there is a need for eye care specialists to routinely refer residents with low vision to low vision rehabilitation specialists as indicated by the ophthalmology practice guidelines.

Implications for Practitioners

The findings of this study have the following implications for practitioners:

• Occupational therapy practitioners are well positioned to identify and address functional limitations imposed by visual impairment.

• Occupational therapists should routinely screen for vision-related functional impairments among residents of retirement communities.

• Non-prescription reading devices may be effective solutions for the occupational therapy generalist to recommend in the interim while referring for appropriate specialty care.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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