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Original Investigation
September 2018

Longitudinal Associations Between Visual Impairment and Cognitive Functioning: The Salisbury Eye Evaluation Study

Author Affiliations
  • 1Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
  • 2Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, the Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 3Department of Human Development and Family Studies, Purdue University, West Lafayette, Indiana
  • 4Department of Statistics, Purdue University, West Lafayette, Indiana
  • 5Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
JAMA Ophthalmol. 2018;136(9):989-995. doi:10.1001/jamaophthalmol.2018.2493
Key Points

Question  How are visual impairment and cognitive function associated with each other over time in older adults?

Findings  In this longitudinal study of 2520 older US adults, visual impairment was associated with declining cognitive function cross-sectionally and over time with worsening vision having a stronger association with declining cognition than vice versa.

Meaning  Visual impairment is adversely associated with future cognitive function in older adults, underscoring the importance of maintaining good vision to mitigate age-related cognitive declines.

Abstract

Importance  Worsening vision and declining cognitive functioning are common conditions among elderly individuals. Understanding the association between them could be beneficial in mitigating age-related cognitive changes.

Objective  To evaluate the longitudinal associations between visual impairment and cognitive function over time in a population-based study of older US adults.

Design, Setting, and Participants  Prospective longitudinal population-based study of older adults in the greater Salisbury area in Maryland. Overall, 2520 community-residing adults aged 65 to 84 years were assessed at baseline between September 1993 and August 1995 (round 1) and 2 (round 2), 6 (round 3), and 8 (round 4) years later.

Main Outcomes and Measures  Visual acuity (VA) was measured using Early Treatment Diabetic Retinopathy Study charts, and cognitive status was assessed using the Mini-Mental State Examination (MMSE).

Results  Of 2520 individuals, the mean (SD) age was 73.5 (5.1) years, 1458 (58%) were women, and 666 (26%) were black. There were 2240 (89%), 1504 (61%), and 1250 (50%) participants in the second, third, and fourth round of study, respectively, with more than half of the loss being due to death. Both VA and MMSE score worsened over time. The mean biannual decline of VA was 0.022 logMAR (approximately 1 line during 8 years; 95% CI, 0.018-0.026), and the mean biannual worsening of MMSE score was −0.59 (95% CI, −0.64 to −0.54; both P < .001). Worse baseline VA was associated with worse baseline MMSE score (r = −0.226; 95% CI, −0.291 to −0.16; P < .001). The rate of worsening VA was associated with the rate of declining MMSE score (r = −0.139; 95% CI, −0.261 to −0.017; P = .03). Cross-lagged models indicated VA in the previous round was associated with MMSE score in the subsequent round (β = −0.995, P < .001), and MMSE score in the previous round was associated with VA in the following round (β = −0.003, P < .001). However, the standardized effect size of VA on MMSE score (β = −0.074; SE, 0.015; P < .001) is larger relative to the reverse effect (β = −0.038; SE, 0.013; P < .001), demonstrating VA is likely the driving force in these dynamic associations.

Conclusions and Relevance  In a population-based sample of older US adults, visual impairment measured at distance is associated with declining cognitive function both cross-sectionally and longitudinally over time with worsening vision having a stronger association with declining cognition than the reverse. Worsening vision in older adults may be adversely associated with future cognitive functioning. Maintaining good vision may be an important interventional strategy for mitigating age-related cognitive declines.

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