Originally Published as "Research Navigator: Age Is Just a Number"

published February 25, 2016

  • How many seniors in the U.S. are blind or visually impaired?
  • How does vision loss change with age? (and what can we expect in the future?)
  • What are key policy and advocacy concerns of older Americans with vision loss?
  • What’s the news about the National Agenda on Vision and Aging and the upcoming AFB Leadership Conference?

Previous editions of the Navigator have presented national-level data about people with vision loss for the entire U.S. population, [school-aged children], and [infants and toddlers]. Now, we will focus on one of the largest demographic concentrations of people who are blind/visually impaired: older Americans. Various agencies and studies have focused on the aging population, and (if you are a regular reader of the Navigator) you won’t be surprised to learn that no single age range “defines” the senior population. For the purposes of this Navigator, we will focus on people ages 65 and up, traditionally referred to as “normal retirement age,” although the Social Security Administration has made changes to gradually increase that age to 67 for people born after 1937 (Social Security Administration, n.d.). Sixty-five is also the age at which most Americans qualify for Medicare. We will also include some information about older and younger age ranges.

Please note that there is more data than we could possibly share in this newsletter, so we have included suggestions of easy-to-access websites and reports with additional data.

How many older Americans have vision loss?

Since many types of vision loss are known to occur later in life, there have been a variety of approaches aimed at better understanding this population. We’ll begin by looking at the major national surveys (also presented in previous Research Navigators), and then we will take a look at other investigations which have only focused on older individuals.

The National Health Interview Survey

The National Health Interview Survey (NHIS), conducted by the Census Bureau for the National Center for Health Statistics (NCHS), surveys civilian, non-institutionalized Americans in approximately 35,000 households each year (approximately 87,500 people) (Centers for Disease Control and Prevention, 2015). NHIS interviewers ask adult respondents “Do you have any trouble seeing, even when wearing glasses or contact lenses?”; if the response is “Yes,” then the interviewer asks, “Are you blind or unable to see at all?”

It is important to know that NHIS data does not include patients in long-term care facilities; therefore – in theory – the NHIS is under-representative of the older population, especially older Americans with significant long-term care needs. In 2012, another NCHS survey estimated that there were 1,383,700 nursing home residents in the U.S. About 85% were over age 64, and 42.3% were over age 84 (Harris-Kojetin, Sengupta, & Valverde, 2013).

Nevertheless, the NHIS provides us one of the largest databases from which to learn about Americans with self-reported vision loss, and because the NHIS has used the same vision questions since 1997, we can look at changes in prevalence over time. (Reminder: prevalence refers to the proportion of a population with a given condition.)

NHIS Year Estimated population with vision loss, ages 65+ Estimated population who are blind ages 65+
2014 6.1 million (13.5%) 350 thousand (0.8%)
2013 6.2 million (14.3%) 420 thousand (1.0%)
2012 5.3 million (12.7%) 410 thousand (1.0%)
2011 5.4 million (13.5%) 340 thousand (0.9%)
2010 5.4 million (13.9%) 400 thousand (1.0%)
2005 6.0 million (17.3%) 420 thousand (1.2%)
2000 5.7 million (17.4%) 400 thousand (1.2%)
1997 5.8 million (18.0%) 381 thousand (1.2%)

(Minnesota Population Center and State Health Access Data Assistance Center, 2016)

Although we know that the overall number of Americans over age 65 has been increasing (due to increased lifespans and the aging of the “baby boom” generation), we can see from this data that there seems to be a slight decrease in the prevalence of both vision loss and blindness. If we narrow our focus to seniors ages 85 and up, percentages significantly increase (22.3% with vision loss and 2.3% experiencing blindness in 2014).

Data users should be aware that the NHIS has a relatively small sample size, made even smaller when we focus only on the older population (for example, the 2014 estimate for ages 65 and up was based on only 15,603 responses). Therefore, we should expect some imprecision in the estimates. As evidence of this, the NHIS reported that they could say with 95% confidence that their 2014 estimate of 13.5% of people self-reporting vision loss is actually somewhere between 12.5% and 14.6%, and the estimate of 0.8% of people ages 65 and up identifying as blind is somewhere between 0.6% and 1.1%. Want to learn more about accessing NHIS data? Watch a recorded webinar, organized by the U.S. Census Bureau, the National Center for Health Statistics, and AFB.

The American Community Survey

The American Community Survey (ACS) is run by the Census Bureau; in 2014, the ACS included interviews with over 2.5 million households and group quarters, a much larger sample size than the National Health Interview Survey. This large sample enables researchers to estimate demographic statistics not only at the national level, but also for smaller geographic regions, even by zip code or school district (for some statistics). However, ACS data on vision loss are based on a slightly different question than the NHIS data. Adult ACS participants are asked “Are you blind or do you have serious trouble seeing, even when wearing glasses?” Like the NHIS, the ACS only surveys civilian, non-institutionalized Americans; unlike the NHIS, the ACS does not include a question specifically about blindness. The ACS provides public access to data for each survey year, as well as for 3-year and 5-year spans (U.S. Department of Commerce, n.d.).

The American Fact-Finder (AFF) web-based tool is an easy (although not very accessible) way to access ACS data. From the AFF, we can quickly retrieve the following estimates from the 2014 ACS data:

  • 1,129,029 adults ages 65-74 with vision difficulty (4.3% of adults in that age range)
  • 1,870,450 adults ages 75 and up with vision difficulty (10.0% of adults in that age range)

(U.S. Census Bureau, 2016)

These data support our conclusions that prevalence of vision loss increases with age. Like NHIS data, ACS figures should be understood as estimates, with some degree of sampling error. Depending on the statistic, the Census Bureau reports that they are 95% confident that the above-reported estimates are accurate within +/- about 10,000 to 15,000 people (this is a much lower margin of error than with the NHIS). Due to the difference between the NHIS and ACS vision questions, we should not compare data from the two surveys.

Want to learn more about the ACS and learn easy ways to create your own customized reports for national, state, and local data? Check out our two Census Bureau-AFB webinars on the ACS data tools American Fact Finder and DataFerrett.

Report: Vision Problems in the U.S.

The organization Prevent Blindness America, in collaboration with the National Eye Institute, produced the report Vision Problems in the U.S., which estimates prevalence of specific types of vision loss based upon U.S. Census figures and data from major epidemiological studies (epidemiology is the study of the patterns of health and disease within a population). The latest version of Vision Problems in the U.S., (2012) provides a diagnoses-specific look at visual impairment for Americans ages 40 and up. The study defines vision impairment as “having worse than 20/40 vision in the better eye, even with eye glasses,” and the study defines blindness according to the United States’ definition of legal blindness, or “visual acuity with best correction in the better eye worse than or equal to 20/200 or a visual field extent of less than 20 degrees in diameter.”

The following are selected estimates for Americans ages 40 and up from the 2012 [Vision Problems in the U.S.](#PBA) (the entire report is available at visionproblemsus.org, including the criteria used when estimating disease prevalence):

  • 2,907,691 people have vision impairment not including blindness (2.0% of the 40 and up population, as estimated by the 2010 Census)
    • 337,752 ages 40-64 (0.33% of the same-age population)
    • 2,569,959 ages 65 and up (6.4% of the same age population)
  • 1,288,275 people are legally blind (0.90% of the 40 and older population, as estimated by the 2010 Census)
    • 155,002 ages 40-64 (0.15% of the same-age population)
    • 1,133,272 ages 65 and up (2.8% of the same-age population)
  • 2,069,403 people have age-related macular degeneration, often called “AMD.”
  • 24,409,978 people have cataract (by age 80, more than half of all Americans have cataract(s)).
  • 7,685,237 people have diabetic retinopathy (which also increases the risk of cataract and glaucoma).
  • 2,719,379 people have glaucoma

This epidemiologically focused study is quite different from self-reported data collected by the NHIS and ACS. While Vision Problems in the U.S. is valuable for its specificity about the causes of vision loss, we must remember that its population figures are based upon findings by physicians and may not be representative of Americans who experience vision loss without having a medical diagnosis from a doctor. Likewise, this study may not reflect the experiences of someone who has better than 20/40 acuities as measured in a doctor’s office but who has trouble seeing or reading due to contrast sensitivity or other optical or visual processing conditions.

Characteristics and projections about older Americans with vision loss

Behavioral Risk Factor Surveillance System

The Behavioral Risk Factor Surveillance System (BRFSS) is a national telephone survey which investigates “health-related risk behaviors, chronic health conditions, and the use of preventative services” (Centers for Disease Control and Prevention [CDC], 2016) through annual interviews with over 400,000 adult U.S. residents. Publicly available analyses of BRFSS data from 2013 report an estimate of 4.4% of the U.S. population experiencing vision loss (identified as “blind or having serious difficulty seeing, even when wearing glasses”) (CDC, 2015).

In previous years (most recently in 2010), the BRFSS optional “Vision Impairment and Access to Eye Care“ module has included two questions about visual function:

  1. How much difficulty, if any, do you have in recognizing a friend across the street?
  2. How much difficulty, if any, do you have reading print in newspapers, magazines, recipes, menus, or numbers on the telephone?

Based upon these responses, a participant would be identified in one of three groups:

  • Those reporting no difficulty recognizing a friend across the street or reading print (no vision loss)
  • Those reporting a little difficulty with distance or near tasks (little vision loss)
  • Those reporting moderate or extreme vision loss with distance and near tasks or unable to do tasks because of eyesight

Researchers have used BRFSS data files to develop more specific estimates and reports, such as The State of Vision, Aging, and Public Health in America, published by the CDC in 2011 based upon 2006-2008 BRFSS data. Some of the important findings from this report include (for adults ages 65 and older with moderate or extreme vision loss):

  • “Cases of early age-related macular degeneration are expected to double by 2050, from 9.1 million to 17.8 million for those aged 50 years or older.
  • Cases of diabetic retinopathy among people aged 65 or older are expected to quadruple by 2050, from 2.5 million to 9.9 million.”

In looking at this data, readers should be reminded that the BRFSS optional vision module was only implemented in 19 states (Arizona, Alabama, Colorado, Connecticut, Florida, Georgia, Indiana, Iowa, Kansas, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Tennessee, Texas, West Virginia, and Wyoming); thus, while efforts were made to make projections about the entire population, we should recognize that the survey did not begin with a very representative sample.

Other sources

There have been additional studies and reports on older Americans with vision loss; however, many are now outdated or are based upon the data sources already mentioned. In 2008, the National Health Interview Survey included a supplementary set of questions related to vision, establishing a baseline for the goals of the Healthy People 2020 initiative; however, despite the need to monitor progress on the Healthy People 2020 goals, this supplement has not been repeated since 2008. (See some of the 2008 results from NIH’s Eye Data site and as well as the webpages for the Healthy People 2020 initiative). Advocates and researchers may also be interested in research related to vision surveillance, conducted by an expert panel at the Centers for Disease Control and Prevention (CDC), available online from the CDC’s Vision Health Initiative website.

Two new initiatives should be on our radar for future publications and data releases related to the population of older Americans with vision loss:

  • The Institutes of Medicine, with sponsorship from the CDC’s Vision Health Initiative (VHI) and others, is convening a consensus study onPublic Health Approaches to Reduce Vision Impairment and Promote Eye Health. You can follow this activity on the IOM website.
  • Through the VHI, CDC has awarded funding for a four-year cooperative agreement to establish a national surveillance system for vision loss and eye health to NORC, a research organization at the University of Chicago. For more information, download this PDF from the VHI.

Using Data to Prompt Policy Change

If you have been following the work of the AFB Public Policy Center, you know that older Americans with vision loss face numerous challenges, ranging from access to information and environments to social inclusion and support and training for caregivers. Public policies which fund and regulate programs for seniors do not always provide the most beneficial options for seniors with vision loss, and advocates are constantly challenged to catch the attention of policymakers who may not be aware of the experiences of constituents who are blind or visually impaired.

Updated data and figures like those presented in this newsletter are vital to demonstrating the need for and impact of policies which address the concerns of our community (and so we must continue to advocate for newer and more comprehensive surveys and studies!). The following are two of AFB’s current key advocacy initiatives related to seniors.

H.R. 729: Medicare Demonstration of Coverage for Low Vision Devices

On February 4, 2015, the AFB Public Policy Center was pleased to announce the introduction of H.R. 729, federal legislation to establish a Medicare demonstration project to assess the fiscal impact of permanent Medicare coverage for these critical devices. The bill is sponsored by Reps. Carolyn Maloney (D-NY) and Gus Bilirakis (R-FL). Efforts to introduce a companion bill in the Senate are ongoing. Once enacted, the bill would make a variety of low vision devices available to Medicare beneficiaries whose eye doctors participate in the five-year demonstration project and prescribe such devices as medically necessary after a clinical evaluation.

H.R. 729 emphasizes that the demonstration project must yield meaningful data for Congress to assess the fiscal impact of permanent Medicare coverage for the most powerful and function-rich devices. Visit the congressional webpage for H.R. 729 to read the bill and see the current list of cosponsors. Contact your Senators and Representative to ask for their support!

Continuing the National Conversation in Aging and Vision Loss

Every 10 years, the White House convenes a national conference to consider the concerns of older Americans. In 2015, the Conference highlighted four themes: healthy aging, long-term services and supports, retirement security, and elder justice. Throughout 2015, AFB gathered extensive feedback from older Americans with vision loss and their families and service providers, which we systematically analyzed according to the White House’s four themes. Our findings were compiled into a report and letter signed by over 70 organizations in the field of blindness and visual impairments, and the letter was sent to the President, congressional issue groups, and numerous federal agencies. Dr. Pris Rogers also wrote an excellent, blog for Vision Aware, describing AFB’s efforts and concerns surrounding the White House Conference on Aging. In a later blog post, Dr. Rogers also shared our disappointment in the lack of attention to older Americans with vision loss in the White House Conference’s final report.

This year’s AFB Leadership Conference (March 3-5, 2016, in Arlington, Virginia) will include a diverse strand of sessions related to aging issues. The first session in this strand will be held the morning of Friday, March 4th, from 10:15 – 12:30. For the session, aging experts and congressional and agency representatives have been invited to participate in a panel discussion on the policy priorities identified in the letter and report. Following an overview of the findings from AFB’s 2015 data collection, the distinguished panelists will each share their perspectives on current and future policy approaches to respond to the needs of older Americans who are blind or visually impaired. Our goal is to reinitiate the National Agenda on Vision and Aging which was developed in the late 1990s. Many of the goals identified in the initial National Agenda are connected with concerns experienced by today’s seniors. For more information, visit AFB’s webpage about the goals of the first National Agenda on Vision and Aging as well as the The National Agenda on Vision and Aging 1998-2005 Report to the Field published in 2005 by Orr, Scott, and Rogers.

Conclusion

Betty Friedan said, “Aging is not lost youth, but a new stage of opportunity and strength” (1994). Today’s seniors can look forward to longer, healthier, more connected lives than ever before. However, we must recognize that vision loss is and will continue to be a part of life for older Americans. The onset and progression of vision loss should not mean an end to “opportunity and strength.” Rather, our national programs for seniors and for people with vision loss must be integrated and easily available nationwide to ensure the right tools, training, and services are in place in the right locations, at the right times to support all seniors and their families. Smart and reliable demographics and other data collection will be essential to identifying, evaluating, and disseminating the best practices for promoting independence and self-determination at any age.

References

Centers for Disease Control and Prevention. (2011). The state of vision, aging, and public health in America. Atlanta: U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov/visionhealth/pdf/vision_brief.pdf

Centers for Disease Control and Prevention. (2015). BRFSS prevalence & trends data. Retrieved from http://www.cdc.gov/brfss/brfssprevalence/

Centers for Disease Control and Prevention. (2016). Behavioral Risk Factor Surveillance System. Retrieved from http://www.cdc.gov/brfss/index.html

Friedan, B. (1994, March 20). How to live longer, better, wiser. Parade Magazine, p. 4-6.

Harris-Kojetin L, Sengupta M, Park-Lee E, Valverde R. (2013). Long-term care services in the United States: 2013 overview. Vital Health Stat, 3(37). Retrieved from National Center for Health Statistics http://www.cdc.gov/nchs/data/nsltcp/long_term_care_services_2013.pdf

Minnesota Population Center and State Health Access Data Assistance Center (2016). IHIS online data analysis system, 2014 NHIS sample. Universe: ((VISION PROB = 0, 1, 2, 7, 8, 9) AND (BLIND = 0, 1, 2) AND (AGE = 0-99)); Weight used: sampweight. Integrated Health Interview Series: Version 6.11. Minneapolis: University of Minnesota. Retrieved from http://ihis.us/

Prevent Blindness America (2012). Vison problems in the U.S. Retrieved from http://visionproblemsus.org/

Social Security Administration (n.d.). Retirement planner: Full retirement age. Retrieved from https://www.ssa.gov/planners/retire/retirechart.html

U.S. Census Bureau (2016). B18103: Sex by age by vision difficulty. Data Set: 2010-2014 American Community Survey 5-year estimates. Retrieved from http://factfinder.census.gov/

U.S. Department of Commerce (n.d.). American Community Survey. Retrieved from http://www.census.gov/programs-surveys/acs/

Next 1997 AFB Video Description Report Highlights