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Sensory Function: Vision and Aging"

Marlon Maus MD, DrPH, FACS UC Berkeley School of Public Health

PH 217C, Tuesday March 5th, 2013

Background Common roots of Public Health and Built Environment Health problems in the 21st Century: effects on older adults Vision in older adults Conclusion

Common Roots of PH and Planning

Schilling, Am J of Prev Med, 2005, The public health roots of zoning: In search of active living s legal genealogy

U.S. Population 1900

Leading Causes Of Death United States: 1900

Of the 30 years of increased life expectancy 1890 1990 5 years can be attributed to medical care.
The rest has come from: Infrastructure (including housing, clean water) Public Health (esp. immunization)

Bunker cited in Prescription for a Healthy Nation Farley and Cohn 2004

The real Leading causes of death United States: 2000

Obese People Worldwide

People with Diabetes Worldwide

25% Obese 7% Diabetic

Obesity: US Adults

Diabetes: US Adults

Childhood obesity
Rates of overweight and obesity have quadrupled among 6-11 year olds in the last three decades Over 9 million American children over the age of 6 are considered obese Cuts life expectancy by 15 years, qualys by 22 years. In CA only 25% of 5th graders met state fitness standards: one mile run, pushups and body mass index measurements

Babey SH, et al. (2009.) Bubbling Over: Soda Consumption and Its Link to Obesity in California. UCLA Center for Health Policy Research. ;

Costs of Diabesity
Diabetes consumes $226 billion or 14% of US healthcare expenditures (2% of GNP) Obesity consumes $147 billion or 9.1% Human cost: increased deaths, cancers, strokes, heart disease, hypertension and reduced quality of life 5 million blind, leading cause 82,000 amputations per year

Diabesitythe causes

Hardee's introduces new Mega-Calorie Monster Thickburger

1410 calories!

107 grams of fat! ---All for $5.49---

7.1 hours of walking!

One 20 Ounce Soda Per Day

17 teaspoons of SUGAR 250 calories 50 gallons per person per year Children and teens 2 cans per day (25% 4 or more!) No. 1 source of calories in our diets Soda portion sizes have increased dramatically.

High Fructose Corn syrup (HFCS)

HFCS: 63 pounds consumed per capita Most common sweetener in processed foods $$$$$ Corn subsidies make it cheap!

Fast food industry spent $4.2 billion in advertisement $294 million targeting children Federal 5 A Day Campaign $9.55 million Center for Nutrition Policy and Promotion.$6.5 million

Exercise for the treatment of depression and anxiety.

Depression and anxiety most common psychiatric conditions 10% of American adults Leading cause of disability Physical activity as effective as medication for depression
International Journal of Psychiatry and Medicine. 2011;41(1):15-28. Carek, PJ et al
Department of Family Medicine, Medical University of South Carolina, Charleston 29406, USA.

Building Design

UC Berkeley School of Public Health. (1959, Welton and Beckett Building )

Stairs Inspired by???

Walkable Neighborhoods

Celebration, Florida

Walkable Neighborhoods
Residents weigh 7 pounds less than in suburbs For every 10 minutes a person spends in a daily car commute, time in community activities falls 10%. Benefits to the environment, our health, our finances, and our communities.

Key elements:
A center People Mixed income, mixed use Parks and public space Pedestrian design Schools and workplaces

Paris, France

First we shape our buildings; thereafter, they shape us.

Health problems in the 21st Century: Diabesity and depression epidemics Common roots of Public Health and Built Environment Collaborations between PH and Planners
Winston Churchill

What is the relation to vision????

>80 million people have potentially blinding diseases Blindness or low vision affects 3.3 million Americans 40 years and older Economic impact: >50 billion dollars in 2002 for health care for individuals with visual disorders (both direct and indirect costs) Estimate: by 2030 the number of visually impaired and legally blind individuals in the US may double Ranks behind arthritis and CVD as the third most common chronic cause of impaired function in persons older than 70 years. Three fourths of all blindness and vision impairment is either preventable or treatable Two-thirds of all blind individuals in the world are female Most are older than 50 years 90% of blind people live in poverty

British Columbia Centre for Epidemiologic & International Ophthalmology (BCEIO), 2000. Healthy People 2010

Statistics BRFSS
Behavioral Risk Factor Surveillance System (BRFSS)
Since 1984 survey of civilian, noninstitutionalized U.S. adults aged 18 years or older 350,000 people surveyed State-based telephone surveillance system. Vision data collected from 19 states that used the supplemental Vision Impairment and Access to Eye Care Module (Vision Module) Provides information about access to eye care, health status, comorbid conditions among older adults. Summarizes the prevalence of vision loss and eye diseases reported by people aged 65 or older

Statistics BRFSS
Prevalence of blindness and vision impairment increases rapidly with age among all racial and ethnic groups, particularly among people older than 75 years. Cases of early age-related macular degeneration are expected to double by 2050, from 9.1 million to 17.8 million for those aged 50 years or older Cases of diabetic retinopathy among people aged 65 or older are expected to quadruple by 2050, from 2.5 million to 9.9 million

Statistics BRFSS

Visual Loss is Associated With.

Decreased quality of life Changes in independent living Increased injury and falls Increased depression Increased isolation Untreated poor vision is associated with cognitive decline and onset of dementia Death
Rogers, MA, Langa KM. Untreated poor vision: a contributing factor to late-life dementia. Am. J. Epidemiol. 2010 171:728

Visual Impairment and Falls

Falls in older adults
Occur in 35-40% of individuals Responsible for 90% of fractures in the elderly Clinical risk factors include vision impairment, gait abnormality and muscle weakness

Fractures associated with

Poor visual acuity in older women Poor contrast sensitivity Decreased depth perception Binocular visual field loss
Coleman AL, el al. J Am Geriatr Soc. 2009; 57:1825. Patino CM el al. Ophthalmology. 2010; 117:199.

Misconceptions Among Elderly

23% ignorant that early eye disease has no noticeable symptoms 27% believe must wait until symptoms before eyes tested 51.4% believe mostly under 40 y/o need eyes checked 30% of people surveyed listed blindness as their greatest fear second to cancer (43%)

(Vision 2020 Australia)

Normal Changes of Aging

Physical changes related to Normal aging ARE NOT disease Changes occur in most body systems to include: Sensory System Brain and Central Nervous System Muscles and Bones Digestion Heart/Circulatory System Respiratory System

Not all older people have impaired vision!
Normal visual changes that occur with aging: Presbyopia: loss of ability to see items that are close up begins in the 40s Decreased contrast sensitivity caused by retinal changes Decreased dark/light adaptation Night vision not as acute Delayed glare recovery. Vitreous Humor Haziness Flashing Lights Moving Spots Color Lens of eye yellows making it more difficult to see red and green colors Discrimination as cones Visual Field Size 1 to 3 degrees per decade

Common Eye Diseases in the United States Associated with Vision Loss
In the U.S., the most prevalent etiologies of vision loss in persons 40 years and older are: AMD (Age-Related Macular Degeneration): 1.6 million age >60 Diabetic Retinopathy: 5.3 million Cataracts: 20.5 million age >65, most prevalent eye disease in older persons and are the leading cause of blindness worldwide Glaucoma: 2.2 million diagnosed, 2 million NOT diagnosed

Vision Problems in the USA NEI/PBA Report: Eye Diseases

Age-Related Macular Degeneration (AMD)

ARMD: leading cause of legal blindness in the USA 9 million people have some form of ARMD 1.6 million have advanced disease accounts for 54 % of all blindness

Age is the greatest risk factor 55-64: one percent are affected 65-74: four percent are affected >75: thirty percent are affected

Other risk factors Smoking. Family history. Obesity. Race. Caucasians are more likely to lose vision from AMD. Women tend to live longer than men, F:M lifetime risk 2:1 6% for females 3% for males

Asymptomatic initially
No pain. Blurred vision. Loss of central vision (reduced visual acuity causing difficulties with detail discrimination) Metamorphopsia (i.e., distortion of objects) Central scotomas Increased glare sensitivity Contrast sensitivity Decreased color vision. Key: Peripheral vision remains intact, and the patient does not progress to total blindness


Normal vision

Same scene as viewed by a person with AMD


Damage of the central retina, or macula Two types Nonexudative (DRY ) drusen (hyaline deposits) and areas of alternating bands of depigmentation/ hyperpigmentation in the retinal pigmented epithelium Exudative (WET) neovascularization

Treatment options: Age-related eye disease study (AREDS): high-dose regimen of vitamin C, vitamin E, beta carotene, and zinc shown to decrease risk of developing vision loss caused by advanced AMD in patients with intermediate AMD or advanced AMD in one eye. Patients without AMD and those with early AMD did not benefit from supplementation. Laser surgery. Photodynamic therapy and intravitreal injections of antivascular endothelial growth factor and corticosteroids have shown promise in treating subsets of patients with macular degeneration. Control of vascular disease risk factors Exercise to increase circulation Sunglasses for UV light protection

What can you do?
Eat a healthy diet Dont smoke, or stop smoking Maintain normal blood pressure Maintain a healthy weight Exercise

Increased ocular pressure that can damage the optic nerve in the eye. Symptoms: Loss of peripheral vision that can lead to decreased central acuity Difficulty functioning in dim light Decreased contrast sensitivity Glare disability Decreased dark/light adaptation Glaucoma can develop in one or both eyes. Primary open-angle glaucoma is the most common


Normal vision

Same scene as viewed by a person with glaucoma

Risk factors: age > 40, hispanic, african american, family history, diabetes, HTN, eye injury, myopia, chronic steroids Treatment: Topical prostaglandins, beta blockers, adrenergics, carbonic anhydrase inhibitors Oral medications Laser therapy Filtering surgery About 50% of individuals with glaucoma are not diagnosed

What can you do?
People at higher risk should get a comprehensive dilated eye exam every one to two years or as instructed by your eye care professional.

Cataract prevalence increases with increasing age 2.6% in the age range 60-69 17% in individuals > 80 Females 20% more likely than males 1/3 of patients with cataract had an unmet need for surgery

Surgery for cataract accounts for

60% of Medicare expenses for vision

Richter, CM et al. Ophthalmology. 2009; 116:2327.

Risk factors and associations: Age Female sex Corticosteroid use Diabetes Smoking Myopia, Ocular UV-B light exposure Bmi >35 Lack of health insurance Low education, Income <$20,000 per year Self-reported barriers to care Last eye exam > 5 years ago

Opacifications of the crystalline lens of the eye Symptoms: Decreased visual acuity, decreased color perception, decreased contrast sensitivity, and glare disability Cloudy or blurred vision Colors that may not appear as bright as they once did.

Poor night vision


Normal vision

Same scene as viewed by a person with cataract

Treatment: Alter prescriptions for eyeglasses or contacts, Surgical extraction

What can you do? Eat a healthy diet. Wear sunglasses and a brimmed hat when outdoors. Dont smoke.

John Taylor, the flamboyant 18th-century British oculist

Diabetic Retinopathy
Leading cause of new blindness in U.S. In adults 20 to 74 years of age. Rapid increase in chance if diabetic for 15+ years Retinal vessels weakened by sorbitol aneurysms leakage retinal damage Other complications: Secondary glaucoma Retinal detachment

Diabetic Retinopathy
Symptoms No early warning signs or symptoms Decreased visual acuity, contrast sensitivity, color perception, and dark/light adaptation, glare disability, distortion, and scotomas Treatment options Early detection and timely treatment can reduce the risk of vision loss.

Laser photocoagulation

Diabetic Retinopathy

Normal vision

Same scene as viewed by a person with diabetic retinopathy

Diabetic Retinopathy
What can you do? Control your ABCs - A1C, blood pressure, and cholesterol. Take your medications as directed. Maintain a healthy weight. Exercise.

Dont smoke.
Have a dilated eye exam at least once a year.

The American Academy of Ophthalmology (AAO) suggests comprehensive medical eye evaluations: For non-diabetics Every 2-4 yrs for patients 40 to 54 years of age Every 1-3 years for patients 55 to 64 years of age 1 or 2 years for patients older than 65 years. For diabetics Normal examination or minimal nonproliferative retinopathy annually Mild to moderate nonproliferative retinopathy without macular edema - every 6 to 12 months Severe nonproliferative diabetic retinopathy every 2 to 4 months

Check visual acuity using standard Snellen chart An impairment of 20/50 or worse or a one-line difference between the eyes should warrant referral Visual fields Fundoscopic exam Amsler Grid