Vision Impairment and the Population Attributable Fraction of Dementia in Older Adults

Abstract

Importance: Vision impairment is a potentially modifiable risk factor for dementia. Although few prior studies have estimated the contribution of vision impairments to dementia, none have reported on multiple objectively measured vision impairments (eg, distance and near visual acuity and contrast sensitivity) in a nationally representative sample of older adults.

Objective: To quantify population attributable fractions of dementia from objective vision impairments in older adults, stratified by age, self-reported sex, self-reported race and ethnicity, and educational attainment.

Design, setting, and participants: This was a population-based cross-sectional analysis in the National Health and Aging Trends Study, which gathers nationally representative information on Medicare beneficiaries aged 65 years and older in the US. A total of 2767 community-dwelling adults eligible for vision and cognitive testing in 2021 were included. Data were analyzed from April to August 2023.

Exposures: Near and distance visual acuity impairments were each defined as >0.30 logMAR. Contrast sensitivity impairment was defined as <1.55 logCS. At least 1 vision impairment was defined as impairment to either near acuity, distance acuity, or contrast sensitivity.

Main outcomes and measures: Adjusted population attributable fractions of prevalent dementia, defined using a standardized algorithmic diagnosis (≥1.5 SDs below mean on 1 or more cognitive domains, self- or proxy-reported dementia diagnosis, or the Ascertain Dementia-8 Dementia Screening Interview Score of probable dementia).

Results: The survey-weighted prevalence of vision impairment among participants aged 71 and older (1575 [54.7%] female and 1192 [45.3%] male; 570 [8.0%] non-Hispanic Black, 132 [81.7%] Hispanic, 2004 [81.7%] non-Hispanic White, and 61 [3.3%] non-Hispanic other) was 32.2% (95% CI, 29.7-34.6). The population attributable fraction of prevalent dementia from at least 1 vision impairment was 19.0% (95% CI, 8.2-29.7). Contrast sensitivity impairment yielded the strongest attributable fraction among all impairments (15.0%; 95% CI, 6.6-23.6), followed by near acuity (9.7%; 95% CI, 2.6-17.0) and distance acuity (4.9%; 95% CI, 0.1-9.9). Population attributable fractions from at least 1 impairment were highest among participants aged 71 to 79 years (24.3%; 95% CI, 6.6-41.8), female (26.8%; 95% CI, 12.2-39.9), and non-Hispanic White (22.3%; 95% CI, 9.6-34.5) subpopulations, with estimates consistent across educational strata.

Conclusions and relevance: The population attributable fraction of dementia from vision impairments ranged from 4.9%-19.0%. While not proving a cause-and-effect relationship, these findings support inclusion of multiple objective measures of vision impairments, including contrast sensitivity and visual acuity, to capture the total potential impact of addressing vision impairment on dementia.

Figure 1.. Dementia Attributable to at Least 1 Vision Impairment and to Contrast Sensitivity, Stratified by Age, National Health and Aging Trends Study (2021)

Panel A displays the age-stratified conditional risk factor prevalence among those with dementia. Error bars for prevalence indicate Wald-type 95% CIs estimated from logistic regression model. Panel B displays age-stratified population attributable fractions (PAFs) of dementia from at least 1 vision impairment (near acuity, distance acuity, or contrast sensitivity) and from contrast sensitivity impairment. Error bars for PAFs indicate nonparametric 95% CIs from 15 000 bootstrapped samples. Near and distance acuity impairment was defined as >0.38 logMAR (Snellen equivalent, >20/40). Contrast sensitivity impairment was defined as <1.55 logCS.

Figure 2.. Dementia Attributable to at Least 1 Vision Impairment and to Contrast Sensitivity, Stratified by Self-Reported Sex, National Health and Aging Trends Study (2021)

Panel A displays the sex-stratified conditional risk factor prevalence among those with dementia. Error bars for prevalence indicate Wald-type 95% CIs estimated from logistic regression model. Panel B displays sex-stratified population attributable fractions (PAFs) of dementia from at least 1 vision impairment (near acuity, distance acuity, or contrast sensitivity) and from contrast sensitivity impairment. Error bars for PAFs indicate nonparametric 95% CIs from 15 000 bootstrapped samples. Near and distance acuity impairment was defined as >0.38 logMAR (Snellen equivalent, >20/40). Contrast sensitivity impairment was defined as <1.55 logCS.

Figure 3.. Dementia Attributable to at Least 1 Vision Impairment and to Contrast Sensitivity, Stratified by Self-Reported Race and Ethnicity, National Health and Aging Trends Study (2021)

Panel A displays the conditional risk factor prevalence among those with dementia, stratified by self-reported race and ethnicity. Error bars for prevalence indicate Wald-type 95% CIs estimated from logistic regression model. Panel B displays population attributable fractions (PAFs) of dementia from at least 1 vision impairment (near acuity, distance acuity, or contrast sensitivity) and from contrast sensitivity impairment, stratified by self-reported race and ethnicity. Error bars for PAFs indicate nonparametric 95% CIs from 15 000 bootstrapped samples. Near and distance acuity impairment was defined as >0.38 logMAR (Snellen equivalent, >20/40). Contrast sensitivity impairment was defined as <1.55 logCS. Race and ethnicity data were collected via self-report and reported because of evidence indicating that vision impairment prevalence varies by race.^, Owing to small numbers in other groups, only data for non-Hispanic Black and non-Hispanic White are reported.