Cognitive Impairment in Low Vision Rehabilitation: Prevalence and Consequences

描述（由申请人提供）： 这项试点研究的目的是描述接受跨学科门诊低视力康复（LVR）的退伍军人中认知障碍的患病率和后果。这是未来干预和实施研究的必要的第一步，旨在改善具有双重视力和认知障碍的退伍军人的结果。 目前有超过100万退伍军人有资格获得LVR，VA提供了良好的康复专家和视觉辅助设备。然而，几乎没有经验证据可以指导可能改善患有视觉和认知缺陷的退伍军人护理的努力，并且需要解决认知缺陷的LVR协议。研究人员先前在非退伍军人人群中的工作表明，多达45%的LVR接受者受到一定程度的认知障碍的影响，即使是轻度的认知障碍也会影响康复成功。 该团队的长期目标是实施具有成本效益的LVR模型，为同时存在视力和认知障碍的人优化功能结果。在附属学术中心，我们的团队成员开发并试点了一种名为记忆或推理增强型低视力康复（MORE-LVR）的新型门诊LVR计划（Whitson et al，JAMA Ophthalmology 2013）。MORE-LVR的许多功能将有助于在VA中实施并吸引退伍军人，但MORE-LVR的某些方面可能与VA中现有的LVR基础设施和实践模式不兼容。这项试点研究将作为必要的第一步，通过填补VA LVR中认知障碍的关键知识空白，使未来的研究成为可能：有必要描述VA低视力诊所中问题的范围，以更好地了解VA特定的障碍和促进因素，以改善服务，并选择适当的措施来衡量这一人群的干预效果。 本申请提出在Hines和达勒姆VA医疗中心的低视力诊所进行一项为期2年的观察性研究。目的1是描述在这些达勒姆和海因斯VA诊所接受门诊低视力服务的退伍军人中认知缺陷的患病率。研究工作人员将对150-200名退伍军人（每个研究中心75-100名）样本进行15分钟的认知测试，这些退伍军人参加门诊、跨学科LVR。从该样本中，将招募40-50名退伍军人（每个研究中心20-25名）参加“纵向队列”。“纵向队列的一半将是退伍军人，他们的测试成绩表明认知障碍;另一半将是年龄匹配的退伍军人，认知正常。对于纵向队列中的每名退伍军人，将招募一名认知完整的同伴（朋友或家庭成员），以提供有关退伍军人结局和LVR经验的其他数据。通过分析基线和90天访视时从40-50名退伍军人/同伴对获得的定量（目标2）和定性（目标3）数据，实现目标2和3。目标2将描述有和无基线认知损害的患者的视觉依赖性功能结局。结果将表明认知障碍可能导致更差的功能结局的程度。进一步的分析将比较该人群中视觉依赖功能的各种指标。目标3将通过与患者和同伴的半结构化访谈的内容分析来识别成功康复的障碍和促进因素。这些见解将为制定符合目标退伍军人和护理人员人群需求、资源和期望的LVR干预措施提供信息。这项试点研究预计将导致一项对照试验，以评估一种特殊设计的LVR服务是否能以VA可接受的增量成本为双重受损退伍军人实现上级结局（与常规LVR相比）。

DESCRIPTION (provided by applicant): The objective of this pilot study is to characterize the prevalence and consequences of cognitive impairment among Veterans receiving inter-disciplinary, outpatient low vision rehabilitation (LVR). This is a necessary first step toward future intervention and implementation research aimed at improving outcomes for Veterans with dual vision and cognitive impairments. Over 1 million Veterans are currently eligible for LVR and the VA provides excellent access to rehabilitation specialists and visual assistive equipment. However, little empiric evidence exists to guide efforts that may improve care for Veterans with both visual and cognitive deficits, and LVR protocols that address cognitive deficits are needed. The investigators' prior work in non-Veteran populations suggests that as many as 45% of LVR recipients are affected by some degree of cognitive impairment, and even mild cognitive deficits can compromise rehabilitation success. This team's long-term goal is to implement cost-effective LVR models that optimize functional outcomes for people with co-existing vision and cognitive impairments. In an affiliated academic center, members of our team developed and piloted a novel outpatient LVR program called Memory or Reasoning Enhanced Low Vision Rehabilitation (MORE-LVR) (Whitson et al, JAMA Ophthalmology 2013). Many features of MORE-LVR would be conducive to implementation in the VA and appealing to Veterans, but some aspects of MORE-LVR may not be compatible with the existing LVR infrastructure and practice patterns within the VA. This pilot study will serve as a necessary first step to enable future research by filling key knowledge gaps regarding cognitive impairment in VA LVR: there is a need to characterize the scope of the problem in VA Low Vision Clinics, to better understand VA-specific barriers and facilitators to improved services, and to select appropriate measures of intervention effectiveness in this population. This application proposes a 2-year observational study in the Low Vision Clinics of the Hines and Durham VA Medical Centers. Aim 1 is to characterize the prevalence of cognitive deficits among Veterans receiving outpatient low vision services at these Durham and Hines VA Clinics. Study staff will administer 15 minutes of cognitive testing to a sample of 150-200 Veterans (75-100 at each site) who present for outpatient, inter- disciplinary LVR. From that sample, 40-50 Veterans (20-25 at each site) will be recruited to participate in a "longitudinal cohort." Half of the longitudinal cohort will be Veterans whose test score indicates cognitive impairment; the other half will be age-matched Veterans with normal cognition. For each Veteran in the longitudinal cohort, a cognitively intact companion (friend or family member) will be enrolled to provide additional data about the Veteran's outcomes and experience in LVR. Aims 2 and 3 will be accomplished by analyzing quantitative (Aim 2) and qualitative (Aim 3) data obtained from the 40-50 Veteran/companion pairs at baseline and 90-day visits. Aim 2 will describe vision-dependent functional outcomes for patients with and without baseline cognitive impairment. The results will indicate the extent to which cognitive impairment may contribute to worse functional outcomes. Further analyses will compare various measures of vision-dependent function in this population. Aim 3 will identify barriers and facilitators of successful rehabilitation through a content analysis of semi-structured interviews with patients and companions. These insights will inform the development of an LVR intervention that is compatible with the needs, resources, and expectations of the target Veteran and caregiver population. This pilot study is expected to lead to a controlled trial to assess whether a speciall designed LVR service achieves superior outcomes (compared to usual LVR) for dually impaired Veterans at acceptable incremental cost to the VA.