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Original Investigation
April 16, 2020

Association of Visual Impairment With Risk of Incident Dementia in a Women’s Health Initiative Population

Author Affiliations
  • 1Byers Eye Institute at Stanford, Palo Alto, California
  • 2Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California
  • 3Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California
  • 4Department of Epidemiology and Population Health, Stanford University, Palo Alto, California
  • 5Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, California
  • 6Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
  • 7Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 8Department of Neurology, University of Southern California, Los Angeles
  • 9Laboratory of Behavioral Neuroscience, National Institute on Aging, Baltimore, Maryland
  • 10Department of Biostatistics and Data Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 11Gillings School of Global Public Health, Department of Epidemiology, University of North Carolina at Chapel Hill
  • 12Department of Ophthalmology, School of Medicine, University of North Carolina at Chapel Hill
  • 13Department of Family Medicine and Public Health, School of Medicine, University of California San Diego, La Jolla
  • 14Department of Medicine, University of Massachusetts Medical School, Worcester
  • 15California Pacific Medical Center Research Institute, San Francisco
  • 16Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 17Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 18Department of Health Research and Policy (Health Services Research), Stanford University, Palo Alto, California
JAMA Ophthalmol. 2020;138(6):624-633. doi:10.1001/jamaophthalmol.2020.0959
Key Points

Question  Is visual impairment associated with women’s risk for developing dementia?

Findings  In this cohort study of 1061 older women, baseline objectively measured visual impairment was associated with a 2- to 5-fold increased risk of dementia over a median 3.8 years of follow-up; 3.1% of participants without objective visual impairment developed dementia vs 8.2% of those with visual acuity of 20/40 or worse. More severe visual impairment was associated with increasingly elevated risk of incident dementia.

Meaning  These results suggest that visual impairment may be a risk factor for dementia; findings are limited by sample size, and more research is needed in a larger population.


Importance  Dementia affects a large and growing population of older adults. Although past studies suggest an association between vision and cognitive impairment, there are limited data regarding longitudinal associations of vision with dementia.

Objective  To evaluate associations between visual impairment and risk of cognitive impairment.

Design, Setting, and Participants  A secondary analysis of a prospective longitudinal cohort study compared the likelihood of incident dementia or mild cognitive impairment (MCI) among women with and without baseline visual impairment using multivariable Cox proportional hazards regression models adjusting for characteristics of participants enrolled in Women’s Health Initiative (WHI) ancillary studies. The participants comprised community-dwelling older women (age, 66-84 years) concurrently enrolled in WHI Sight Examination (enrollment 2000-2002) and WHI Memory Study (enrollment 1996-1998, ongoing). The study was conducted from 2000 to the present.

Exposures  Objectively measured visual impairment at 3 thresholds (visual acuity worse than 20/40, 20/80, or 20/100) and self-reported visual impairment (determined using composite survey responses).

Main Outcomes and Measures  Hazard ratios (HRs) and 95% CIs for incident cognitive impairment after baseline eye examination were determined. Cognitive impairment (probable dementia or MCI) was based on cognitive testing, clinical assessment, and centralized review and adjudication. Models for (1) probable dementia, (2) MCI, and (3) probable dementia or MCI were evaluated.

Results  A total of 1061 women (mean [SD] age, 73.8 [3.7] years) were identified; 206 of these women (19.4%) had self-reported visual impairment and 183 women (17.2%) had objective visual impairment. Forty-two women (4.0%) were ultimately classified with probable dementia and 28 women (2.6%) with MCI that did not progress to dementia. Mean post–eye examination follow-up was 3.8 (1.8) years (range, 0-7 years). Women with vs without baseline objective visual impairment were more likely to develop dementia. Greatest risk for dementia was among women with visual acuity of 20/100 or worse at baseline (HR, 5.66; 95% CI, 1.75-18.37), followed by 20/80 or worse (HR, 5.20; 95% CI, 1.94-13.95), and 20/40 or worse (HR, 2.14; 95% CI, 1.08-4.21). Findings were similar for risk of MCI, with the greatest risk among women with baseline visual acuity of 20/100 or worse (HR, 6.43; 95% CI, 1.66-24.85).

Conclusions and Relevance  In secondary analysis of a prospective longitudinal cohort study of older women with formal vision and cognitive function testing, objective visual impairment appears to be associated with an increased risk of incident dementia. However, incident cases of dementia and the proportion of those with visual impairment were low. Research is needed to evaluate the effect of specific ophthalmic interventions on dementia.

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