Social function and associated factors among the elderly with visual impairment in northeast China: a cross-sectional study

doi:10.21203/rs.3.rs-1608907/v1

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Social function and associated factors among the elderly with visual impairment in northeast China: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-1608907/v1

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Purpose: The purpose of this study was to investigate the status of social function in the elderly with visual impairment and analyzed the influencing factors of social function.

Methods: The general information, social function, anxiety and depression of 211 elderly persons with visual impairment were investigated by general information questionnaire, WHO Disability Assessment Schedule 2.0(WHO-DAS Ⅱ) and Hospital Anxiety and Depression Scale(HADS). The data were described by frequency, percentage, mean ± standard deviation, median and quartile. Univariate analysis and multiple linear regression were used to describe the influencing factors of social function in the elderly with visual impairment.

Results: The average score of social function of the elderly with visual impairment was 50.10 ±15.470, the score range was 10 to 87. 211 cases of elderly with visual impairment had social function impairment, 198 cases (93.84%) had moderate or above impairment. Univariate analysis showed that there were significant differences in age, residence status, diabetic retinopathy, vision status, anxiety and depression degree of social function impairment (P<0.05). Multiple regression results showed that age, visual status, residence status, anxiety and depression were the influencing factors of social function in the elderly with visual impairment (P<0.05).

Conclusions: The social function damage of the elderly with visual impairment is more serious, especially with advanced age, poor vision and poor psychological quality.

Older adults

visual impairment

Social function

Influencing factors

Vision disorders

Visual impairment refers to a decline in visual clarity, which is defined as poor vision or blindness(1). According to the Global Burden of Disease Study (GBD), disabilities caused by sensory injuries such as visual impairment are the second leading cause of disability in the world(2), with about 42 million people going blind and 290 million people with moderate or above visual impairment in 2019(3). According to the data of the second national sample survey of the disabled, the prevalence rate of visual impairment in China's elderly population is 6.77%, and the number of people with visual impairment is 13 million, accounting for about 70% of the total population with visual disabilities in the country(4). In addition, from 1990 to 2019, the age-standardized prevalence rate of moderate visual impairment in China was much higher than the global average (1.48%), with the highest increase among G20 countries(5). Visual impairment as an age-related disease, the prevalence rate of visual impairment increases twice as much as 10 years old in people over 40 years old(6). It is speculated that as the country with the largest population and increasing aging in the world, the size of the elderly population with visual impairment is expanding year by year. Visual impairment in the elderly caused by limited movement(7), falls(8), increased risk of death(9) and other problems, resulting in a major global public health burden, seriously damaged the social function of the elderly(10, 11).

At present, foreign studies on the impact of visual impairment on the social function of the elderly mostly focus on six different aspects: cognition, mobility, self-care, getting along with people, life activities and social participation. Some scholars believe that cognitive function is related to the degree of visual impairment, and visual impairment will lead to the decline of cognitive function(12, 13). Other scholars have proposed that visual impairment has no effect on cognitive function(14), or even helps to maintain cognitive function and physical health(15). Through the investigation and analysis of the elderly with vision loss in three French cities, Pérès and other researchers found that the loss of vision will lead to the limitation of activities such as going up and down stairs and walking(16). Visual impairment not only restricts the living activities of the elderly, but also reduces the self-care ability of the elderly(17). Crews et al.(18)conducted a survey on the social participation of the elderly over 70 years old and found that compared with ordinary elderly people, the frequency of communication between the visually impaired and their friends was significantly lower. Visual impairment also reduces elderly people's participation in social activities(19). It can be seen that foreign scholars have conducted many studies on the social function of the elderly with visual impairment, involving a wide range of aspects. However, they are mostly limited to exploring the impact of visual impairment on a single aspect of social function, and do not systematically evaluate the social function of the elderly with visual impairment as a whole. However, previous studies in China on social function mostly focus on patients with mental disorders who have body image or cancer patients(20, 21), and there are no reports on the status of social function of the elderly with visual impairment in the context of Chinese culture. Currently, there is a lack of specific social function scale for the visually impaired elderly, and some studies have pointed out that the WHO Disability Assessment Schedule 2.0 (WHO-DAS Ⅱ) has cross-disease and cultural applicability(22, 23), and can be used to evaluate the social function of the visually impaired elderly.

Therefore, the purpose of this study was to investigate the social functioning of the elderly with visual impairment in China by using the WHO Disability Assessment Scale, and to analyze the factors influencing the social functioning of the elderly with visual impairment.

2.1 Participant

A total of 211 elderly patients with visual impairment were selected from the ophthalmology ward of two Grade 3A Hospital in Shenyang, Liaoning Province from October 2020 to July 2021. Inclusion criteria: ①Age ≥ 60 years old; ②Meet the national visual impairment (visual disability) assessment standard; ③Clear consciousness, good hearing, normal intelligence and communication; ④Sign informed consent. Exclusion criteria: ①A history of severe mental illness; ②Patients with serious heart, brain, kidney and joint diseases.

2.2 Instrument

(1) The general data questionnaire for elderly patients with visual impairment

It was designed by the researchers according to the purpose and content of the study. The contents of the questionnaire include demographic sociological data (gender, age, ethnic groups, degree of education, monthly household income, marital status, living status, home place, type of medical payment, etc.), smoking, drinking, disease-related data (ophthalmopathy type, vision status).

(2) 32 items in Chinese version of the WHO Disability Assessment Schedule (WHO-DAS Ⅱ)(24)

The scale is used to evaluate the social function of the visually impaired elderly, with a total of 32 items. Six different functional areas, such as cognition, mobility, self-care, getting along, life activities and participation, were scored in specific areas. Each item option "none", "mild", "moderate", "severe" and "extreme" was scored as 1–5 in turn. The higher the score is, the more serious the damage to social function is. Specific scoring criteria(25): 0–4 as no injury; 5–24 as mild injury; 25–49 as moderate injury; 50–95 as severe injury; 96–100 as complete injury. The reliability and validity of the scale was good, the Cronbach's α coefficient was 0.86, and the intra-group correlation coefficient was 0.98(26).

(3) Hospital Anxiety and Depression Scale (HADS)(27)

It is used to evaluate the anxiety and depression of the elderly with visual impairment and to explore the influencing factors of social function in the elderly with visual impairment. Compiled by Zigmond and Snaith, it is one of the most commonly used tools for clinical screening of non-psychotic anxiety and depression in somatic diseases. It has been used in China since 1993. The scale contains 14 items, including 7 items of odd items for anxiety and 7 items of even items for depression. Likert 4 score was used for each item, and the higher the score, the more serious the degree of anxiety or depression. Among them, 0–7 was normal, 8–10 was mild anxiety (depression), 11–15 was moderate anxiety (depression), and 16–21 was severe anxiety (depression). The Cronbach's α coefficient values were about 0.8 for the anxiety subscale and the depression subscale(28).

2.3 Date collection

After obtaining the informed consent of the subjects, following the principle of voluntary participation, using unified guidance to explain the purpose, significance and matters needing attention of this survey, the researchers issued the general situation questionnaire, HADS and WHO-DAS II to the subjects by themselves. The patients filled out the questionnaire with the help of one-on-one researchers, and those with limited vision or low education level were explained one by one by the researchers and filled in the answers instead.

2.4 Data analysis

Two people enter data at the same time, and SPSS 22.0 was used for data processing and analysis. The counting data are expressed in frequency and percentage, the measurement data in accordance with normal distribution are described by mean ± standard deviation, and the measurement data of non-normal distribution are described by median and quartile. Analysis of variance and rank sum test were used in univariate analysis, and multiple regression was used in multivariate analysis. P < 0.05 was considered as statistically significant difference.

3.1 Social demographic characteristics

In this study, there were 93 males (44.08%) and 118 females (55.92%). The youngest is 60 years old, the oldest is 92 years old, and the average age is (69.70 ± 7.25) years old. Other details are shown in Table 1.

Table 1

Social demographic characteristics
characteristics	n(%)	characteristics	n(%)
Gender		Degree of education
Male	93(44.08)	Primary school and below	52(24.64)
Female	118(55.92)	Junior middle school	98(46.45)
Age(yrs.)		Senior high school	45(21.33)
60–69	124(58.77)	University and above	16(7.58)
70–79	60(28.43)	Living status
≥ 80	27(12.80)	Live alone	26(12.32)
Ethnic groups		Live with children	46(21.80)
Han	194(91.94)	Live with a spouse	139(65.88)
Others	17(8.06)	Payment type
Marital status		Medical insurance	192(91.00)
Married	159(75.35)	Out-of-pocket payment	19(9.00)
Divorced	4(1.90)	Monthly household income
Widow/widower	48(22.75)	≤ 3 thousand	64(30.33)
Home place		> 3, ≤ 5 thousand	65 (30.81)
Rural areas	49(23.22)	> 5, ≤ 10 thousand	70(33.18)
Town	162(76.78)	> 10 thousand	12(5.69)

3.2 The status of social function in the elderly with visual impairment

The social function score of 211 elderly patients with visual impairment was 50.10 ± 15.47, 13 with mild injury (6.16%), with an average score of 20.90 ± 3.80, 83 with moderate injury (39.34%), with an average score of 38.29 ± 6.69, and 115 with severe injury (54.50%), with an average score of 61.93 ± 8.20, and there is no elderly with no injury or complete injury of social function. The scores of cognition, mobility, self-care, getting along, life activities and participation are 38.63 ± 15.25, 43.19 ± 19.68, 39.91 ± 23.18, 64.10 ± 2.69, 72.51 ± 24.80, 52.19 ± 16.45, respectively.

3.3 The results of univariate analysis of social function damage

Age, living condition, diabetic retinopathy, visual acuity, anxiety and depression had influence on the score of social function impairment, and the difference was statistically significant (P < 0.05), as shown in Table 2.

Table 2

Results of single factor analysis (n = 211)
Items	n(%)	Social function M ± SD	F/H	P
Age(yrs.)			7.107	.001
60–69	124(58.77)	47.34±15.27
70–79	60(28.43)	51.85±14.47
≥ 80	27(12.80)	58.90±15.19
Living condition			6.526¹⁾	.038
Live alone	26(12.32)	45.11±13.49
Live with children	46(21.80)	53.83±14.42
Live with a spouse	139(65.88)	51.09(24)²⁾
Diabetic retinopathy			4.538¹⁾	.033
No	162(76.78)	49.06±15.06
Yes	49(23.22)	57.61(20)²⁾
Eyesight			9.559	< .001
< 0.02	19(9.00)	60.30±13.77
≥ 0.02, < 0.05	19(9.00)	59.61±12.13
≥ 0.05, < 0.1	21(9.95)	56.21±12.76
≥ 0.1, < 0.3	152(72.04)	46.80±15.18
Anxiety			41.769	< .001
Normal	80(37.91)	39.39±13.21
Mild	74(35.07)	52.03±12.57
Moderate	48(22.75)	61.32±10.44
Severe	9(4.27)	69.69±10.40
Depression			37.921	< .001
Normal	53(25.12)	36.53±12.01
Mild	55(26.07)	47.96±14.56
Moderate	80(37.91)	56.56±11.49
Severe	23(10.90)	64.04±11.80
¹⁾ Rank sum test; ²⁾ Median (quartile)

3.4 Multiple regression Analysis of influencing factors of Social function

In order to clarify the influence of each variable on the social function impairment of the elderly with visual impairment, the statistically significant factors in the univariate analysis were taken as independent variables, and the social function impairment was divided into dependent variables. Multiple regression analysis was done, and the assignment of independent variables was shown in Table 3.

Table 3

Independent variable assignment table
Independent variable	Assignment method
Age(yrs.)	60–69 = 1, 70–79 = 2, ≥ 80 = 3
Living condition	Setting dumb variables with reference to living alone, X₁ = Live with children (0,1), X₂ = Live with spouse (0,1)
Diabetic retinopathy	No = 0, Yes = 1
Eyesight	< 0.02 = 1, ≥ 0.02 and < 0.05 = 2, ≥ 0.05 and < 0.1 = 3, ≥ 0.1 and < 0.3 = 4
Anxiety	Original data entry
Depression	Original data entry
Social function	Original data entry

The results of multivariate analysis showed that age, living condition, eyesight, anxiety and depression all entered the regression equation (P < 0.05), that is, anxiety, visual condition, age, depression and living status were the influencing factors of social function in the elderly with visual impairment. 54.3% of the total variation of social function in the elderly with visual impairment was explained as shown in Table 4.

Table 4

Results of multiple regression analysis of social function impairment (n = 211)
	B	SE	Beta	t	P
Constant	20.923	4.602	-	4.547	< .001
Anxiety	2.319	0.439	0.426	5.278	< .001
Eyesight	-3.652	0.757	-0.233	-4.823	< .001
Age	4.980	1.082	0.229	4.603	< .001
Depression	0.823	0.351	0.189	2.342	.020
Live with children	7.918	2.614	0.212	3.030	.003
Live with spouse	5.426	2.350	0.167	2.309	.022
R² = 0.543, adjusted R² = 0.529, F = 40.360, P < .001

4.1 The degree of social function impairment in the elderly with visual impairment is serious.

211 elderly patients with visual impairment were accompanied by mild or more social function damage, and 198 (93.84%) had moderate or above injury. It can be seen that the social function impairment rate of the elderly with visual impairment is high, and the injury is more serious. The impairment of social function of the visually impaired elderly is particularly prominent in four aspects: life activities, getting along with other, social participation and moving around. This shows that visual impairment has a great impact on the self-care, family functions, interpersonal communication and activities of daily life of the elderly, and it is difficult for the elderly to adapt to the life changes brought about by the decline of eyesight. Some studies have pointed out that even if the visual impairment of the elderly is mild, their social function damage is also relatively large, and the impact caused by the injury is wide and involves many aspects(29, 30). Chia et al.(31) used the quality of Life scale (SF-36) to conduct a cross-sectional study on people with unilateral visual impairment aged 49 and above in the Blue Mountains area. It was found that unilateral visual impairment could cause significant damage to social function, but bilateral visual impairment was more serious than unilateral visual impairment. This phenomenon may be caused by the fact that eyes, as an important organ for people to contact and observe the outside world, play a vital role in life. Impaired vision will inevitably lead to limitations in many aspects, such as daily life activities, thus causing damage to people's social function.

4.2 Analysis of influencing factors of social function in the elderly with visual impairment

4.2.1 Vision

The results of data analysis showed that the score of social function had a significant difference in the degree of decline of visual acuity (P < 0.05), and the results of multivariate analysis showed that the degree of social function impairment decreased with the improvement of vision. Previous studies have shown that the severity of visual impairment is a factor affecting social function, and the more serious the visual impairment is, the worse the social function is (31–33)and the lower the quality of life is(34). Although the subjects and the evaluation tools used in these studies are different from those in this study, the results are basically the same. In addition, the safety problems of accidental injuries such as falls and bruises and the limitation of activities caused by decreased eyesight will further aggravate the damage of social function to a certain extent(35–37). Therefore, the level of social function can be improved by actively treating primary diseases and preventing accidental injuries.

4.2.2 Advanced age

Multiple regression analysis showed that advanced age was a risk factor for social function in the elderly with visual impairment. Previous studies have proved that there is a strong correlation between age and social function, and the damage of social function becomes more serious with the increase of age(31), which is consistent with the results of this study. The reason for this phenomenon may be that the physiological decline of vision caused by the increase of age leads to the impairment of social function(34), and some sick elderly people may also mistakenly regard the decrease of pathological vision as normal organ aging, thus delaying the treatment of the disease and aggravating the degree of damage to social function. In addition, with the increase of age, the function of other organs, activity ability and thinking ability of the human body will gradually weaken, and the body resistance and the ability to adapt to environmental changes will become worse, which also makes the social function of the visually impaired elderly prone to damage.

4.2.3 Living condition

Statistical data showed that the impairment of social function of the visually impaired elderly living with their spouses or children was more serious than that of the elderly living alone (P < 0.05). The reason may be that after visually impaired older persons living with their children or spouses, their families worry that they will not be able to complete the housework on their own or are influenced by traditional culture that illness means that they need to be more cared for, and their original self-care behavior and housework activities are partially or entirely done by their families, which leads to deprivation of family responsibilities and increased dependence of older persons with visual impairment, which leads to impaired social function. In addition, the reason for the difference may also be that the eyesight of the elderly living alone is relatively good, or because the visually impaired elderly living alone need to complete their daily life independently, this possibility of being forced to communicate with the outside world makes their social function better retained.

Leung et al.(34) conducted a cross-sectional study on visual function and quality of life of healthy elderly in Hong Kong. The results show that the social function of the elderly who live with others is better, which is contrary to the results of this study. The reason for the difference may be that the elderly in the community in this study have relatively good eyesight and need less care. In this case, the healthy elderly who live alone have less contact with society than those who live with others. Therefore, their social function has been weakened to a certain extent.

4.2.4 Anxiety

There is a certain correlation between the impairment of social function and the occurrence of anxiety symptoms in the elderly with visual impairment, but according to the existing research results, the causal relationship between them is not clear. The results of this study point out that there is a positive correlation between anxiety and the impairment of social function in the elderly with visual impairment, and anxiety is the influencing factor of social function, that is, the occurrence of anxiety will aggravate the damage of social function in the elderly with visual impairment(38–43). This is basically consistent with the results of most studies at present. The reason is that, as an important sensory organ of the human body, the functional impairment of the eye is prone to anxiety symptoms(44), and the advanced age itself is the promoting factor of anxiety, which leads to the obvious anxiety performance of the elderly with visual impairment(45, 46). To a certain extent, the occurrence and development of anxiety impaired social function(43). Lefèvre et al.(47) pointed out that the improvement of social function helps to reduce the symptoms of anxiety, that is, the level of social function is the influencing factor of anxiety, which is obviously different from the results of multivariate analysis in this study. The reason for this difference may be the researchers' different definition of social function, or the inconsistency of the evaluation tools used by the researchers, or the possibility that anxiety and social function influence each other. Previous studies on the relationship between social function and anxiety are mostly cross-sectional studies with small sample size, or short follow-up time, the accuracy of the conclusions need to be further considered, it is recommended to carry out a large sample, long-term follow-up study.

4.2.5 Depression

Depressive symptoms are one of the more common emotional disorders, which will increase the probability of disability in the elderly, reduce the possibility of health recovery, and then damage social function and reduce the quality of life(48, 49). From this study, we can conclude that the depression of the visually impaired elderly is closely related to social function. Although previous studies have seldom dealt with the correlation between depressive symptoms and social function in the elderly with visual impairment, the existing results of other diseases have proved that there is a correlation between depression and social function, and depression is a risk factor of social function(50). Oliveri et al.(51) compared the scores of social function and depressive symptoms in 218 patients with schizophrenia and 154 healthy controls. The results showed that the correlation between depression and social function in the two groups was similar, and the social function of patients was largely determined by the degree of depression, and it was proved that depressive symptoms were independent factors of social function. In addition, the results of a randomized controlled study to explore the effects of depressive symptoms on social function showed that the social function of patients improved with the relief of depressive symptoms(52). According to the existing literature and combined with the results of this study, it can be concluded that depressive symptoms can damage the social function of the elderly with visual impairment. Therefore, the improvement of social function of the elderly with visual impairment can be considered to reduce the degree of depression in patients.

The source of the population in this study is limited by region, and most of them are urban residents, and there is a lack of people living in nursing homes, so the results cannot be fully extended to the visually impaired elderly population in China. And this study is a cross-sectional survey, and the accuracy of the causal relationship between variables needs to be further verified. It is suggested that a large sample, multicenter, long-term cohort study or randomized controlled study should be carried out in the future to further clarify the causal relationship among the factors.

The results of this study show that the social function of the elderly with visual impairment is more serious, and the influencing factors are various. Attention should be paid to the elderly patients with visual impairment with advanced age, poor vision and poor psychological quality. In the future, the intervention on the social function of the elderly with visual impairment can start from the treatment of primary diseases, improve eyesight, improve the psychological status of patients, retain more independent activities and so on.

WHO-DAS Ⅱ: WHO Disability Assessment Schedule 2.0; HADS: Hospital Anxiety and Depression Scale

Ethical approval and Consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the First Hospital of China Medical University (no. 15/2019). Informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable

Availability of data and materials

The datasets analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

No conflict of interest has been declared by the authors

Funding

This work was supported by the National Natural Science Foundation of China (grant numbers 71974198)

Author’ Contributions

All authors contributed to the study conception and design. Data collection were performed by WZ, ZFX, APW. Data analysis: WZ, SL; The first draft of the manuscript was written by WZ and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Thanks to all the questionnaire developers for their contributions and all the patients who participated in the study.

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No competing interests reported.

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Social function and associated factors among the elderly with visual impairment in northeast China: a cross-sectional study

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Abstract

1. Introduction

2. Methods

2.1 Participant

2.2 Instrument

2.3 Date collection

2.4 Data analysis

3. Results

3.1 Social demographic characteristics

3.2 The status of social function in the elderly with visual impairment

3.3 The results of univariate analysis of social function damage

3.4 Multiple regression Analysis of influencing factors of Social function

4. Discussion

4.1 The degree of social function impairment in the elderly with visual impairment is serious.

4.2 Analysis of influencing factors of social function in the elderly with visual impairment

4.2.1 Vision

4.2.2 Advanced age

4.2.3 Living condition

4.2.4 Anxiety

4.2.5 Depression

5. Limitations

6. Conclusion

Abbreviations

Declarations

References

Additional Declarations

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