An age-cohort study of older adults with and without visual impairments: activity, independence, and life satisfaction.

Abstract: This survey of 560 older adults who were visually impaired or sighted analyzed whether the two groups differed in their levels of activity, independence, and life satisfaction and the degree to which activity and independence contribute to the prediction of life satisfaction. Implications for rehabilitation services are discussed.

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There is no doubt that the onset of a visual impairment can result in the loss of independence; the ability to participate in activities; and, in many cases, a reduction in one's satisfaction with life (Branch, Horowitz, & Carr, 1989; Crews & Campbell, 2001; D'Argent-Molina, Hays, & Breart, 1996; Davis, Lovie-Kitchin, & Thompson, 1995; Heyl & Wahl, 2001; Kaarlela, 1978; Keller, Morton, Thomas, & Potter, 1999; Langlois, Norton, Campbell, & Leveille, 1999; Ringering & Amaral, 1990; Salive et al., 1994; Verbrugge & Patrick, 1995; Wahl, Schilling, Oswald, & Heyl, 1999). There is a question, however, about how the impact of these losses, often associated with impaired vision, fits into the general context of aging. There are many reasons why people experience a loss of independence and activity as they age; hence, changes and losses that are due to visual impairment may not be so different from those that are due to other age-related factors. Thus, the following questions must be asked: Do older people who are visually impaired differ greatly from the general population of older persons in their levels of activity and independence? If so, to what extent do these differences affect their satisfaction with life?

We used data from a survey of older people who were sighted or visually impaired to determine if those who were visually impaired were less active, independent, and satisfied with life than were those who were sighted and to assess the degree to which age, visual status, activity, and independence predict levels of life satisfaction in this population.

Methods

The study was conducted in accordance with the tenets of the Declaration of Helsinki and was approved by the Massey University Human Ethics Committee, Palmerston North, New Zealand. A questionnaire was administered to all registered members of the Royal New Zealand Foundation of the Blind (RNZFB) who were aged 65 or older and living in private dwellings in the Manawatu region of the lower North Island of New Zealand and to sighted persons of the same age group. To be a registered member of the RNZFB, one has to have either a visual acuity of 6/24 (20/80) or worse in the better eye with corrective lenses or a field of vision not greater than 20 degrees at its widest diameter (RNZFB, 2004). The sighted comparison group was randomly selected from the voter registration rolls for the region restricted by age (65 years or older) and residence (private dwellings). No member of the comparison group was found to meet the eligibility criteria for registration with RNZFB. Thus, each member of the comparison group was considered sighted for the purposes of the study.

The questionnaire included questions to screen for registration or eligibility for registration with RNZFB, age, gender, marital status, ethnicity, income, level of education, occupation, size of the community in which they lived, and number of impairments other than vision. It also included the following measures: (1) an Independence Inventory, in which the participants ranked their independence in 12 domains of daily living (such as personal management, kitchen management, and active recreation) (Good, 2005a); (2) the Frenchay Activities Index (Holbrook & Skilbeck, 1983), which measures the frequency of meal preparation, social activities, reading, and so forth); and (3) the Satisfaction with Life Scale (Diener, Emmons, Larsen, & Griffin, 1985), in which the participants agreed or disagreed with such statements as "In most ways, my life is close to the ideal." The participants were provided the survey materials in their preferred formats, and telephone and face-to-face assistance was available on request. Surveys were returned in a postage-paid envelope, provided by the researcher (the first author). Surveys took approximately 30 minutes to complete and 40 minutes if completed with assistance. Three participants requested telephone assistance with the survey, and 60 participants requested that the researcher provide face-to-face assistance.

Results

DEMOGRAPHIC CHARACTERISTICS OF THE PARTICIPANTS

Of the 560 participants, 135 were visually impaired and 425 were sighted. No significant differences were found between the two groups on ethnicity, education, previous occupation, or income (see Table 1). Significant differences were found on age, gender, size of the communities in which they lived, marital status, and number of impairments other than vision. When considered by age cohort, however, all other significant differences between the groups disappeared. The group who was visually impaired (M = 82.3, SD = 6.76) was significantly older than the comparison group: M = 74, SD = 6.49; t (558) = 12.86, p < .001.

As a group, the participants closely reflected the older population of New Zealand, in general, and of the Manawatu region, in particular, in terms of the distribution of age, ethnicity, marital status, educational level, previous occupation, income, health impairments, and living situations (Health Funding Authority, 1998; MidCentral District Health Board, 2004; Statistics New Zealand, 2004).

ACTIVITY, INDEPENDENCE, AND LIFE SATISFACTION

A two-way between-groups analysis of variance (ANOVA) was conducted to explore the impact of visual status and age on the frequency of activity, independence, and life satisfaction across the three age cohorts: Cohort 1 (aged 65-74), Cohort 2 (aged 75-84), and Cohort 3 (aged 85-100) (see Table 2). A statistically significant main effect was found for age [F (2, 546) = 3.27, p = .039] on activity. The effect size was small (partial [[eta].sup.2] = .012). Post hoc comparisons, using the Tukey's Honestly Significant Difference test for equal variances, indicated that the mean activity score for Cohort 1 (M = 3.1, SD = 0.68) was significantly greater than that for Cohort 2 (M = 2.85, SD = 0.76) and Cohort 3 (M = 2.58, SD = 0.79). The mean score for Cohort 2 was also significantly greater than that for Cohort 3. There was also a significant main effect for visual status on activity [F (1,546) = 15.88, p < .001], with those with visual impairments (M = 2.56, SD = 0.75) having a significantly lower mean activity score than those in the comparison group (M = 3.04, SD = 0.72). The effect size was small (partial [[eta].sup.2] = .029). No interaction effect between age and visual impairment on activity was found IF (2, 546) = 0.22, p = .800].

A significant main effect was also found for age (see Table 3) [F (2, 555) = 12.63, p < .001] on independence. The effect size was small to moderate (partial [[eta].sup.2] = .044). Post hoc comparisons using the Tamhane's T2 test (because variances were not equal) indicated that the mean independence score for Cohort 1 (M = 2.73, SD = 0.37) was significantly higher than that for Cohort 2 (M = 2.51, SD = 0.55) and Cohort 3 (M = 2.10, SD = 0.69) and that the mean independence score for Cohort 2 was significantly higher than that for Cohort 3. A significant main effect was found as well for visual status [F (1,555) = 78.08,p < .001] on independence. The mean independence score for the group with visual impairments (M = 2.05, SD = 0.69) was significantly lower than that for the comparison group (M = 2.70, SD = 0.38). The effect size was moderate to large (partial [[eta].sup.2] = .125). No interaction effect for age and visual status on independence was found [F (2, 555) = 0.76, p = .468].

A statistically significant main effect was found for visual status on life satisfaction [F (1, 560) = 14.31, p < .001], and the effect size was small (partial [[eta].sup.2] = .025) (see Table 4). The mean life satisfaction score for the visually impaired group (M = 21.72, SD = 6.58) was significantly lower than that for the sighted group (M = 24.40, SD = 5.87). No effect on life satisfaction was found for age.

[FIGURE 1 OMITTED]

However, as Figure 1 indicates, a significant interaction effect of age and vision on life satisfaction was found [F (2, 560) = 5.75, p = .003]. The effect size, in this case, was also small (partial [[eta].sup.2] = .020). A follow-up analysis of simple effects was conducted with a one-way ANOVA that explored the effects of age on satisfaction with life separately for the two groups. Significant differences across the three age cohorts were found within the group with visual impairments, but not within the comparison group. Post hoc comparisons using Tamhane's T2 test found a significant difference in the group with visual impairments between Cohorts 2 (M = 20.5, SD = 6.37) and 3 (M = 24.19, SD = 5.22), with those in Cohort 3 having a higher level of life satisfaction. Those in Cohort 1 (M = 19.05, SD = 8.95) did not differ significantly from those in Cohort 2 or Cohort 3.

Hierarchical multiple regression analysis was used to determine the degree to which levels of independence and activity predicted life satisfaction when the effects of age and visual status were controlled. Thus, age and visual status (visually impaired or sighted) were entered as independent variables in the first step of this analysis (Model 1) (Tobachnick & Fidell, 1996). Activity and independence scores were entered as independent variables in the second step (Model 2). As can be seen in Table 5, age and visual status, entered in Model 1, explain just 3.5% ([R.sup.2] change = .035) of the variance in life satisfaction. When independence and activity were entered in Model 2, the model as a whole explained 6.2% (total [R.sup.2] change = .062) of the variance in life satisfaction. Thus, activity and independence were found to explain an additional 2.7% ([R.sup.2] change = .027) of the variance in life satisfaction when age and visual status were controlled. Three of the four variables that were entered were found to make a unique and significant contribution to the prediction of life satisfaction, with visual status ([beta] = .127, p = 0.14) making the greatest contribution, followed by independence ([beta] = .115, p = .029) and activity ([beta] = .107, p = .023). Although statistically significant, the level of prediction was not great.

Discussion

Independence and frequency of activity were found to be lower for the older age cohorts and for those with visual impairments. This finding is similar to what has been found in other studies (Jette & Branch, 1985; Kington, Rogowski, Lillard, & Lee, 1997). This knowledge, that both age and vision affect activity and independence, may assist older people and those who provide rehabilitation or instruction in daily living skills to set more reasonable and informed goals. Understanding that their age-related peers are all experiencing diminished activity and independence may help people to adjust their expectations of themselves and of rehabilitation, which, in turn, may enhance their self-esteem, satisfaction, and rehabilitation. The findings of this study support the findings of Clark, Bond, & Sanchez (1999) and Levasseur, Desrosiers, & St.-Cyr Tribble (2008) that age must be considered an important contributor to the reduction in activities, just as visual impairment is.

In this study, satisfaction with life was found to be lower overall for those who were visually impaired, as has been found in most previous research, with a few exceptions. The unusual finding that the oldest age cohort with visual impairments had a higher score on life satisfaction than did the younger age cohorts with visual impairments or the older sighted cohorts may be a result of resilience and accumulated flexibility and skills for coping. It could also be explained by Festinger's (1954) social comparison theory, which was recently applied in studies related to older people (Cheng, Fung, &Chan, 2007). In the oldest age group (aged 85 or older), the group with visual impairments functioned more like the sighted group. For the first time as older people, this oldest group with visual impairments may have been able to compare themselves favorably to their sighted peers in terms of daily functioning, which may explain their higher levels of life satisfaction.

Having sight, being more independent, and being more active were the three factors that were found to be significant predictors of higher life satisfaction. Although each factor made a significant and unique contribution to life satisfaction, more than 93% of the variance in overall life satisfaction remains unexplained. It is clear that activity and independence, although frequently emphasized in rehabilitation programs for those who are blind or have low vision, may not be key to improving or maintaining life satisfaction. Although essential for survival, adaptive independent living skills do not appear to have a great influence on life satisfaction. Other, yet unexplored, factors must be considered when providing rehabilitation services to older clients (see the discussion of such factors in Good, In press).

The limitations of this study include the fact that, undoubtedly, other unexplored variables may have an impact on life satisfaction for this population. Cross-sectional, rather than longitudinal, data were explored, which limits inferences that can be made regarding causality. The study was undertaken within a specific regional area, where rehabilitation services, transportation services, disability support, and community activities make their own unique contributions to the lives of the population under study. The findings may be generalizabile, to various degrees, in other communities where rehabilitation services have been established for a longer period, where older people who are visually impaired have more skilled or less skilled role models, or where services are more available or less available to older people. Although the sample sizes of the groups varied significantly, they were large enough to accommodate these differences. For the most part, the sample sizes represented the general age structure of age cohorts in New Zealand and in RNZFB registration statistics. Few participants were able to report their visual acuities, and the descriptions of their visual function that were provided did not allow for a clear classification of the degrees of visual impairment. Because accurate data on the degree of visual impairment were not obtained, the analysis of the influence of the degrees of visual impairment on activity, independence, and life satisfaction was limited. Alternative explanations of these results could be related to skewed scales or missing data, although the number of participants was high enough to accommodate these differences and multivariate statistical assumptions were met on multivariate tests with the untransformed data.

New Zealand and the Manawatu region, in particular, have some unique attributes that could affect the generalizability of the findings. Home ownership and independent living is high among older New Zealanders; fewer than 1% of the population in the Manawatu region live in retirement villages, and this number does not appear to be rising (personal communication with the retirement commissioner of New Zealand, May 22, 2008; Vision Manawatu, 2007). The Manawatu region is considered to be rural and has a high proportion of drivers of private vehicles and few dignified options for nondrivers, since it does not have a high-quality accessible public transportation system (Davey & Nimmo, 2003). Governmental supports for older people are relatively generous and include practical assistance in the home, which allows for some formalized social supports as well. Home help organizations allow for social time between clients and home help supporters (personal communications with the Lavender Blue Home Help Organisation, SupportLinks Manawatu, March 16, 2005). In the Manawatu region, there is a tightly knit community of RNZFB members who provide opportunities for social contact among members and allow for social comparisons, which may enhance life satisfaction.

Future directions

Although a plethora of studies have assessed the impact of visual impairments on children and working-aged adults, few have identified the impact on those aged 65 and older. There is even less information on the needs of older people with visual impairments in the older age cohorts of 65-74, 75-84, and 85 or older or what aspect of visual impairment is most directly related to life satisfaction. Future studies on the particular aspects of visual impairment that relate most closely to life satisfaction would assist those who provide direct rehabilitation services to this population. Likewise, information about the tasks that specific age groups find most difficult and that create dissatisfaction, especially in relation to age-related peers, would be useful in understanding how best to assess the needs of older people with visual impairments, to plan their rehabilitation goals, to provide instruction to them, and ultimately to improve their satisfaction with life. Professional preparation of those who will work in the field of vision rehabilitation must include more comprehensive information on aging, in general, and on how older people who are visually impaired differ from their sighted peers, so that a better understanding of expectations may assist service providers, older people with visual impairments, and their families.

Older people with visual impairments are underserved and misunderstood. Providers of vision rehabilitation services do not always understand aging or older people in general and may not know when to push clients or when to accept that they may not want or need to learn skills for independence. Data from this study can enhance the understanding of what to expect of older clients with visual impairments in rehabilitation in the context of the norms of performance of their peers, both sighted and visually impaired. People do not necessarily know what to expect of themselves as they age or as they age with visual impairments. The findings of this study could lend strength to the argument for improved education for older adults with visual impairments and for those who are preparing to provide rehabilitation services about activity and independence levels that could be expected of individuals in specific age cohorts of older people. With an enhanced understanding of how older people who are visually impaired differ from their sighted peers, professionals in the field of visual impairment can address these gaps and educate people about how they function like their peers, which may reduce their anxiety or feelings of being different from their peers. This information will be useful in assisting researchers, educators, service providers, families, and older persons who are visually impaired to understand how the functioning of those with visual impairments may be similar to or different from that of sighted persons so as to gain a greater understanding of expectations of performance of skills for daily living and ultimately to improve life satisfaction.

References

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Gretchen A. Good, Ph.D., senior lecturer, School of Health and Social Services, Massey University, Private Bag 11222, Palmerston North, New Zealand; e-mail: <[e-mail]>. Steven LaGrow, Ed.D., professor, School of Health and Social Services, Massey University; e-mail: <s.j. [e-mail]>. Fiona Alpass, Ph.D., senior lecturer, School of Psychology, Massey University; e-mail: <[e-mail]>.

Table 1
Demographic characteristics of the participants.

                                                         Combined
                                                           group
                                                         (N = 560)

Characteristic                                           n       %

Age (years)
  65-74                                                 258    46.1
  75-84                                                 218    38.9
  85+                                                    84    15.0
Gender
  Male                                                  240    42.9
  Female                                                320    57.1
Ethnicity
  New Zealander of European descent                     504    90.6
  New Zealander of Maori descent                         20     3.6
  New Zealander of Pacific Island descent                 1     0.2
  Other (includes European, Asian, Pacific
    Islander, Indian, Australian, and North American)    31     5.6
  Missing data                                            4     0.7
Size of community (population)
  Main urban area (30,000+)                             214    38.2
  Secondary urban area (10,000-29,000)                  132    23.6
  Minor urban area (1,000-10,000)                       126    22.5
  Rural center (300-1,000)                               32     5.7
Rural area (outside town boundaries)                     56    10.0
  Current living situation
  Alone                                                 207    37.0
  With spouse or partner                                309    55.2
  With children                                          16     2.9
  With spouse or partner and children                    11     2.0
  With other family members                              11     2.0
  With nonfamily members                                  6     1.1
  Other                                                   0     0
Marital status
  Married                                               330    58.9
  Not married                                            44     7.9
  Widowed                                               185    33.0
  Missing data                                            1     0.2
Occupation or former occupation
  Homemaker                                             144    26.8
  Legislator, administrator, or manager                  18     3.3
  Professional                                           83    15.4
  Associate professional or technician                   25     4.6
  Clerk                                                  60    11.2
  Service or sales worker                                39     7.2
  Agriculture or fishery worker                          52     9.7
  Trades worker                                          66    12.3
  Plant and machine operator or assembler                30     5.6
  Elementary occupation                                  21     3.9
  Missing data                                           22     3.9
Educational qualification
  No school qualification                               214    39.3
  School certificate pass                               107    19.6
  Matriculation or university entrance or higher         39     7.2
  Trade apprenticeship, professional certificate
    or diploma                                          109    20.0
  Governmental examination for public service            24     4.4
  University degree, diploma, or certificate             52     9.5
  Missing data                                           15     2.7

                                                         Visually
                                                         impaired
                                                         (N = 135)

Characteristic                                           n       %

Age (years)
  65-74                                                  16    11.9
  75-84                                                  68    50.4
  85+                                                    51    37.8
Gender
  Male                                                   46    34.1
  Female                                                 89    65.9
Ethnicity
  New Zealander of European descent                     121    89.6
  New Zealander of Maori descent                          5     3.7
  New Zealander of Pacific Island descent                 1     0.7
  Other (includes European, Asian, Pacific
    Islander, Indian, Australian, and North American)     8     5.9
  Missing data                                            0     0
Size of community (population)
  Main urban area (30,000+)                              62    45.9
  Secondary urban area (10,000-29,000)                   33    24.4
  Minor urban area (1,000-10,000)                        30    22.2
  Rural center (300-1,000)                                4     3.0
Rural area (outside town boundaries)                      6     4.4
  Current living situation
  Alone                                                  68    50.4
  With spouse or partner                                 53    39.3
  With children                                           7     5.2
  With spouse or partner and children                     1     0.7
  With other family members                               4     3.0
  With nonfamily members                                  2     1.5
  Other                                                   0     0
Marital status
  Married                                                56    41.5
  Not married                                             9     6.7
  Widowed                                                70    51.9
  Missing data                                            0     0
Occupation or former occupation
  Homemaker                                              44    33.8
  Legislator, administrator, or manager                   4     3.1
  Professional                                           11     8.5
  Associate professional or technician                    9     6.9
  Clerk                                                  11     8.5
  Service or sales worker                                11     8.5
  Agriculture or fishery worker                          14    10.8
  Trades worker                                          12     9.2
  Plant and machine operator or assembler                10     7.7
  Elementary occupation                                   4     3.1
  Missing data                                            5     3.7
Educational qualification
  No school qualification                                59    45.0
  School certificate pass                                24    18.3
  Matriculation or university entrance or higher         13     9.9
  Trade apprenticeship, professional certificate
    or diploma                                           23    17.6
  Governmental examination for public service             7     5.3
  University degree, diploma, or certificate              5     3.8
  Missing data                                            4     3.0

                                                          Sighted
                                                         (N = 425)

Characteristic                                           n       %

Age (years)
  65-74                                                 242    56.9
  75-84                                                 150    35.3
  85+                                                    33     7.8
Gender
  Male                                                  194    45.6
  Female                                                231    54.4
Ethnicity
  New Zealander of European descent                     383    91.0
  New Zealander of Maori descent                         15     3.6
  New Zealander of Pacific Island descent                 0     0
  Other (includes European, Asian, Pacific
    Islander, Indian, Australian, and North American)    23     5.5
  Missing data                                            4     0.9
Size of community (population)
  Main urban area (30,000+)                             152    35.8
  Secondary urban area (10,000-29,000)                   99    23.3
  Minor urban area (1,000-10,000)                        96    22.6
  Rural center (300-1,000)                               28     6.6
Rural area (outside town boundaries)                     50    11.8
  Current living situation
  Alone                                                 139    32.7
  With spouse or partner                                256    60.2
  With children                                           9     2.1
  With spouse or partner and children                    10     2.4
  With other family members                               7     1.6
  With nonfamily members                                  4     0.9
  Other                                                   0     0
Marital status
  Married                                               274    64.5
  Not married                                            35     8.2
  Widowed                                               115    27.1
  Missing data                                            1      .2
Occupation or former occupation
  Homemaker                                             100    24.5
  Legislator, administrator, or manager                  14     3.4
  Professional                                           72    17.6
  Associate professional or technician                   16     3.9
  Clerk                                                  49    12.0
  Service or sales worker                                28     6.9
  Agriculture or fishery worker                          38     9.3
  Trades worker                                          54    13.2
  Plant and machine operator or assembler                20     4.9
  Elementary occupation                                  17     4.2
  Missing data                                           17     4.0
Educational qualification
  No school qualification                               155    37.4
  School certificate pass                                83    20.0
  Matriculation or university entrance or higher         26     6.3
  Trade apprenticeship, professional certificate
    or diploma                                           86    20.8
  Governmental examination for public service            17     4.1
  University degree, diploma, or certificate             47    11.4
  Missing data                                           11     2.6

Note: (Good, 2005a, 2005b.)

Table 2
Frequency of activity, by age cohort, and visual status.

                    Frequency of activity

                           65-74

Age cohort           n       M      SD

Visually impaired    16    2.71    0.71
Sighted             236    3.13    0.67
Missing cases         6
Total               258    3.10    0.68

                    Frequency of activity

                           75-84

Age cohort           n       M      SD

Visually impaired    66    2.59     0.80
Sighted             148    2.97    00.71
Missing cases         4
Total               218    2.85     0.76

                        Frequency of activity

                           85-100

Age cohort           n       M      SD     Total N

Visually impaired    49    2.47    0.07       131
Sighted              31    2.74    0.93       415
Missing cases         4                        14
Total                84    2.58    0.79       560

Note: The Frenchay Activities Index consists of 21 items and a
composite score of frequency of activity: 1 = never, 2 = less than
1 day per week, 3 = 1-3 days per week, 4 = 4-6 days per week, and 5
= 7 days per week.

Table 3
Independence scores, by age cohort, and visual status.

                        Independence

                           65-74

Age cohort           N      M      SD

Visually impaired     16   2.31   0.48
Sighted              240   2.75   0.35
Missing cases          2
Total                258   2.73   0.37

                       Independence

                           75-84

Age cohort           n      M      SD

Visually impaired     66   2.10   0.68
Sighted              149   2.69   0.36
Missing cases          3
Total                218   2.51   0.55

                        Independence

                           85-100

Age cohort           n      M      SD    Total N

Visually impaired     51   1.91   0.74       133
Sighted               33   2.39   0.49       422
Missing cases          0                       5
Total                 84   2.10   0.69       560

Note: The Independence Inventory consists of 96 items and 12
subscales. Composite scores: 0 = de-pendent or does not apply,
1 = lots of assistance, 2 = some assistance, 3 = independent.

Table 4
Satisfaction with life scores means, by age cohort, and visual status.

                    Satisfaction with life

                          65-74

Age cohort           n      M      SD

Visually impaired    16   19.05   8.95
Sighted             242   24.85   5.69
Total               258   24.49   6.08

                    Satisfaction with life

                          75-84

Age cohort           n      M      SD

Visually impaired    68   20.50   6.37
Sighted             150   23.90   6.10
Total               218   22.84   6.37

                       Satisfaction with life

                          85-100

Age cohort           n      M      SD    Total N

Visually impaired    51   24.19   5.21       135
Sighted              33   23.39   6.01       425
Total                84   23.88   5.52       560

Note: Range = 5-35; a higher score reflects a higher
level of satisfaction. Adapted from Good, In press.

Table 5
Hierarchical multiple regression of age, visual status, activity,
and independence as predictors of satisfaction with life.

                                                     [R.sup.2]
Predictor variables           B      SE     [beta]    change       p

Step 1                                               .035 *
  Age                        .051   .040     .061                .207
  Visual status (impaired
    or not impaired)        1.830   .742     .127                .014

Step 2                                               .027 *      .001 *
  Activity                   .877   .385     .107                .023 *
  Independence              1.290   .592     .115                .029 *
Total [R.sup.2]                                      .062 *
N = 560
F(2,560) = 8.872

* p [less than or equal to] .05.