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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
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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
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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 Australia
30 - 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.
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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