Cognitive Impairment in Low Vision Rehabilitation: Prevalence and Consequences

描述(由申请人提供)： 这项初步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。这是迈向未来干预和实施研究的必要的第一步，旨在改善患有双重视力和认知障碍的退伍军人的结果。目前有100多万退伍军人有资格接受LVR，退伍军人管理局为康复专家和视觉辅助设备提供了极好的途径。然而，几乎没有经验证据来指导可能改善对患有视觉和认知缺陷的退伍军人的护理的努力，需要解决认知缺陷的LVR方案。研究人员之前在非退伍军人群体中的工作表明，多达45%的LVR接受者受到不同程度的认知障碍的影响，即使是轻微的认知障碍也会影响康复的成功。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。在一个附属的学术中心，我们团队的成员开发并试点了一项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等人，《美国医学会眼科学杂志》2013年版)。More-LVR的许多功能将有助于在退伍军人中实施并吸引退伍军人，但More-LVR的某些方面可能与退伍军人管理局现有的LVR基础设施和实践模式不兼容。这项试验性研究将作为未来研究的必要的第一步，通过填补有关退伍军人低视力认知障碍的关键知识空白：需要确定退伍军人低视力诊所问题的范围，更好地了解退伍军人特有的障碍和改善服务的促进者，并选择适当的干预措施来衡量这一人群的干预效果。这项申请提出了一个为期两年的观察性研究，在Hines和Durham VA医学中心的低视力诊所进行。目标1是描述在这些达勒姆和海因斯退伍军人诊所接受门诊低视力服务的退伍军人中认知缺陷的流行率。研究人员将对150-200名退伍军人(每个地点75-100名)进行15分钟的认知测试，这些退伍军人代表门诊跨学科的LVR。从该样本中，将招募40-50名退伍军人(每个地点20-25名)参加一个“纵向队列”。纵向队列的一半将是测试分数表明认知障碍的退伍军人；另一半将是年龄匹配、认知正常的退伍军人。对于纵向队列中的每个退伍军人，将招募一名认知完好的同伴(朋友或家人)，以提供关于退伍军人在LVR中的结果和经验的额外数据。目标2和目标3将通过分析在基线和90天访问时从40-50名退伍军人/同伴对获得的定量(目标2)和定性(目标3)数据来实现。目标2将描述有和没有基线认知障碍患者的视觉依赖功能结果。结果将表明认知障碍可能在多大程度上导致较差的功能结果。进一步的分析将比较这一人群中视觉依赖功能的各种衡量标准。目标3将通过对患者和同伴的半结构化访谈的内容分析，确定成功康复的障碍和促进者。这些见解将为LVR干预的发展提供信息，使其与目标退伍军人和照顾者群体的需求、资源和期望相兼容。这项试点研究预计将导致一项对照试验，以评估特殊设计的LVR服务是否以退伍军人退伍军人可接受的增量成本为双侧受损退伍军人实现了更好的结果(与通常的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.